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Full text of "A treatise on surgery; by American authors. For students and practitioners of surgery and medicine"

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The original of this book is in 
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There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104225234 



CONTRIBUTORS. 



BELFIELD, WILLIAM T., M. D. ; 
BEVAN, ARTHUR DEAN, M. D.; 
BLAKE, CLARENCE J., M. D. ; 
BRADFORD, EDWARD H., M. D. ; 
BULL, CHARLES STEDMAN, M. D. : 
BURRELL, HERBERT L., M. D. ; 
DELAVAN, D. BRYSON, M. D. ; 
DENNIS, FREDERIC S., M.D.; 
ETHERIDGE, JAMES H., M. D. ; 
EVE, DUNCAN, M. D. ; 
FORDYCE, JOHN A., M. D. ; 
GERRISH, FREDERIC H, M. D. ; 
GERSTER, ARPAD G., M. D. ; 
HARD AWAY, WILLIAM A., M. D. ; 
HARE, HOBART AMORY, M. D. ; 
HOLLO WAY, JAMES M., M. D. ; 
KELSEY, CHARLES B., M. D. ; 
LOVETT, ROBERT W., M. D. ; 
MATAS, RUDOLPH, M. D. ; 
MUDD, HENRY H, M. D. ; 
NANCREDE, CHARLES B., M. D. ; 
PARK, ROSWELL, M. D. ; 
PARKER, CHARLES B., M. D. ; 
PARMENTER, JOHN, M. D. ; 
RANSOHOFF, JOSEPH, M. D. ; 
RICHARDSON, MAURICE H, M. D. 
SMITH, CHAUNCEY P., M.D.; 
SOUCHON, EDMOND, M. D. 



A 



Treatise on Surgery 



BY 



AMERICAN AUTHORS. 

FOR STUDENTS AND PRACTITIONERS OF SURGERY 
AND MEDICINE. 

EDITED BY 

^ROSWELL PARK, A.M., M.D, 

Pbofessoe of the Principles and Practice of Surgery and of Clinical Surgery in the 

Medical Department of the University of Buffalo, Buffalo, New-York; Member 

of the Congress of German Surgeons; Fellow of the American Surgical 

Association; Ex-President Medical Society of the State of New 

York ; Surgeon to the Buffalo General Hospital, etc. 



CONDENSED EDITION, WITH EEVISIONS. 



"WITH 625 ENGrBAVIHGS AND 37 FULL-PAGE PLATES 
IN COLOKS AND MOBTOCHBOME. 




LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 
1899. 



M<5-^ ^ c \<\ 

Entered according to Act of Congress in the year 1899, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



WESTCOTT Sl THOMSON. 
ELECTROTYPERS, PHlLADA. 



PREFACE. 



The success achieved by this work has exceeded the most sanguine 
expectations, though it was reasonable to assume that a thoroughly 
modern treatise on surgery by the most experienced teachers and sur- 
geons of America would not fail of appreciation. The great demand 
for the work in its two-volume form brought with it sufficient indica- 
tions to warrant the belief that a somewhat condensed edition in a single 
volume and at a correspondingly lower price would add to its popu- 
larity. Advantage has been taken of this opportunity to revise the 
work to date, though, as it was really in advance of the time at its orig- 
inal issue, no organic changes have been found necessary. The essen- 
tially new treatment originally bestowed upon certain topics has been 
approved ; for instance, the distinction everywhere maintained between 
Hyperemia and Inflammation (i. e., Infection), the insistence upon the 
practical importance of Bacteriology, and the development of the sub- 
jects of Auto-intoxications and the Surgical Sequela? of Acute Non- 
surgical Diseases. The novel chapter on the Surgical Pathology of the 
Blood has justified the belief that the exact methods of clinical study 
so useful to the modern physician would be appreciated by his surgical 
confrb-e. 

In thus presenting the most modern results of research and experi- 
ence, care has at the same time been taken not to neglect the vast amount, 
of accumulated knowledge which is our heritage from the past, and unre- 
mitting effort has been devoted to afford under each topic a complete 
and condensed account of theory and practice representing the science 
and art of Surgery in its advanced position of to-day. Recent years 
have witnessed great progress in medical education toward the highest 
standards, and this tendency in the direction of a beneficent uniformity 
has rendered practicable the preparation of a text-book answering the 
requirements of the continually increasing proportion of students who 
seek the advantages of our best institutions. Their needs cannot be 
sharply differentiated from those of the student after graduation ; hence 
it is believed that this work will be found practically serviceable by the 
surgeon and the general physician desiring surgical information. 

That two editions of a work should be simultaneously extant is a 

5 



6 PREFACE. 

novelty worthy of comment. Eeaders desiring the fuller information 
in the two-volume edition will naturally prefer it. The condensed 
edition maintains the convenient division into General and Special 
Surgery, and thus preserves the conformity of the work with the sur- 
gical courses rapidly becoming universal. It will answer the needs of 
students as well as of those who desire a comprehensive and practical 
single-volume work on modern surgery. The reduction in price, pro- 
portionately much greater than the reduction in matter, is an advan- 
tage which all readers will appreciate, and one which has only been 
rendered practicable by the exceedingly wide sale already achieved. 

Especial care has been devoted to the very complete series of illus- 
trations, of which by far the greater part have been prepared expressly 
for this work. Colored plates have been introduced wherever they 
would best serve to elucidate the text. 

The Editor again desires to express his warmest thanks to the emi- 
nent contributors. He would also acknowledge his indebtedness to 
Charles E. Smith, Esq., of Philadelphia, and to Chauncey P. Smith, 
M. D., of Buffalo, for invaluable assistance ; also to Dr. Irving P. Lyon, 
for the supervision of the drawings and the beautiful original prepara- 
tions from which Plate I. was made. 

EOSWELL PARK. 

Buffalo, September, 1899. 



CONTRIBUTORS. 



WILLIAM T. BELFIELD, M.D., 

Assistant Professor of Surgery, Rush Medical College, Chicago; Professor of 
Genito-urinary and Venereal Diseases, Chicago Polyclinic. 

ARTHUR DEAN BEVAN, M.D., 

Professor of Anatomy, Rush Medical College, Chicago; Professor of Surgery, 
Women's Medical . School, Northwestern University, Chicago; Surgeon to the 
Presbyterian, St. Luke's, and St. Elizabeth's Hospitals, Chicago. 

CLARENCE J. BLAKE, M.D., 

Professor of Otology, Medical School of Harvard University, Boston ; Aural Sur- 
geon to the Massachusetts Charitable Eye and Ear Infirmary, Boston. 

EDWARD H. BRADFORD, M.D., 

Assistant Professor of Orthopaedic Surgery, Medical School of Harvard Univer- 
sity, Boston ; Surgeon to the Children's Hospital, Boston. 

CHARLES STEDMAN BULL, A. M., M. D., 

Professor of Ophthalmology, Medical Department, Cornell University, New 
York ; Surgeon to the New York Eye Infirmary ; Consulting Ophthalmic 
Surgeon to St. Luke's, Presbyterian, and St. Mary's Hospitals, New York. 

HERBERT L. BURRELL, M. D., 

Assistant Professor of Clinical Surgery, Medical School of Harvard University, 
Boston ; Surgeon to The Boston City Hospital and to The Children's Hospital, 
Boston. 

D. BRYSON DELAVAN, A.B., M.D., 

Chief of Clinic, Diseases of Throat, etc., College of Physicians and Surgeons, New 
York ; Professor of Laryngology and Rhinology, New York Polyclinic ; Con- 
sulting Laryngologist to the New York Cancer Hospital, the Hospital for Rupt- 
ured and Crippled, and the Macdonough Hospital, New York ; Ex- President 
of the American Larvngological Association, etc. 

FREDERIC S. DENNIS, M. D, M. R. C. S. Eng., 

Professor of Clinical Surgery, Cornell University, New York City ; Attending 
Surgeon to Bellevue and St. Vincent Hospitals ; Consulting Surgeon to the Mon- 
tefiore Home, New York City, and St. Joseph's Hospital, Yonkers, N.Y. ; Mem- 
ber of the German Congress of Surgeons, Berlin. 

7 



8 CONTRIBUTORS. 

JAMES H. ETHEEIDGE, A. M., M. D. (Deceased), 

Formerly Professor of Obstetrics and Gynecology, Eush Medical College, Chicago ; 
Professor of Gynecology, Chicago Polyclinic ; Gynecologist to the Presbyterian 
and Polyclinic Hospitals ; Consulting Gynecologist to the St. Joseph Hospital, 
Chicago. 

DUNCAN EVE, A. M., M. D., 

Professor of Surgery and Clinical Surgery, Medical Department of Vanderbilt 
University, Nashviile, Tennessee ; Chief Surgeon to the Nashville, Chattanooga 
and St. Louis Railway Co. ; Consulting Surgeon to the Nashville City Hospital. 

JOHN A. FOEDYCE, A. M., M. D., 

Professor of Dermatology and Syphilology, University and Bellevue Hospital 
Medical College, New York ; Visiting Dermatologist to the City (Charity) 
Hospital, New York 

FEEDEEIC H. GEEEISH, A.M., M. D., 

Professor of Anatomy, Bowdoin College ; Consulting Surgeon to the Maine General 
Hospital, Portland, Maine. 

AEPAD G. GEESTEE, M. D., Ch. D., O. M., Vienna, 

Visiting Surgeon to the Mt. Sinai Hospital, and Consulting Surgeon to the German 
Hospital, New York ; Ex-President of the New York Surgical Society. 

WILLIAM A. HAEDAWAY, A. M., M. D., 

Professor of Diseases of the Skin and Syphilis, Washington University, St. 
Louis; Ex-President of the American Dermatological Association. 

HOBAET AMOEY HAEE, M. D., B.Sc, 

Professor of Therapeutics and Materia Medica, Jefferson Medical College, Phila- 
delphia; Physician to the Jefferson Medical College Hospital, Philadelphia. 

JAMES M. HOLLOWAY, A.M., M.D., 

Professor of Surgery and Clinical and Operative Surgery, Medical Department, 
Kentucky University, Louisville. 

CHAELES B. KELSEY, M. D, 

Professor of Abdominal and Eectal Surgery, New York Post-Graduate Medical 
School and Hospital, New York. 

ROBERT W. LOVETT, M.D., 

Surgeon to the Infants' Hospital and Assistant Surgeon to the Children's Hospital, 
Boston. 

EUDOLPH MATAS, M. D., 

Professor of General and Clinical Surgery, Medical Department, Tulane Uni- 
versity of Louisiana, New Orleans ; Visiting Surgeon to the Charity Hospital 
of New Orleans, etc. 



CONTRIBUTORS. 9 

HENEY H. MUDD, M. D., 

Professor of Clinical Surgery and Special Fractures and Dislocations, St. Louis 
Medical College ; Consulting Surgeon to the St. Louis City Hospital. 

CHAELES B. NANCBEDE, A. M., M. D., LL. D., 

Professor of Surgery and of Clinical Surgery, Department of Medicine and Sur- 
gery, University of Michigan; Emeritus Professor of General and Orthopedic 
Surgery, Philadelphia Polyclinic. 

EOSWELL PAEK, A.M., M. D, 

Professor of Principles and Practice of Surgery and Clinical Surgery, Medical 
Department of the University of Buffalo; Surgeon to the Buffalo General 
Hospital, etc., Buffalo, N. Y. 

CHAELES B. PAEKEE, M.D., M. E. C. S. Eng., 

Professor of Clinical Surgery, Cleveland College of Physicians and Surgeons, 
Cleveland, Ohio. 

JOHN PABMENTEB, M. D., 

Professor of Anatomy and of Clinical Surgery, Medical Department of the Uni- 
versity of Buffalo; Surgeon to the Erie County, Fitch Accident, and Children's 
Hospitals, Buffalo, X. Y. 

JOSEPH EANSOHOFF, M. D, F.E.C.S., 

Professor of Anatomy and Clinical Surgery, Medical College of Ohio, Cincinnati ; 
Surgeon to the Good Samaritan, Cincinnati, and Jewish Hospitals. 

MAUEICE H. EICHAEDSOX, A.B., M.D., 

Assistant Professor of Clinical Surgery, Medical School of Harvard University, 
Boston ; Visiting Surgeon to the Massachusetts General Hospital, Boston. 

CHAUNCEY P. SMITH, M.D., 

Assistant Attending Surgeon to the Fitch Accident Hospital ; Assistant Attending 
Surgeon to the Buffalo General Hospital ; Instructor in Surgery, Medical De- 
partment, University of Buffalo. 

EDMOND SOUCHON, M. D., 

Professor of Anatomy and Clinical Surgery, Medical Department, Tulane Uni- 
versitv of Louisiana, New Orleans ; Visiting Surgeon to the Charity Hospital, 
New Orleans. 



CONTENTS. 

PART I. 

SUEGICAL PATHOLOGY. 

By Roswell Park, M.D. 



CHAPTER I. 

PAGE 

HYPEREMIA : ITS CONSEQUENCES AND TREATMENT . 17 

CHAPTER II. 
SURGICAL PATHOLOGY OF THE BLOOD 29 

CHAPTER III. 

INFLAMMATION 44 

CHAPTER IV. 

ULCER AND ULCERATION 72 

CHAPTER V. 

GANGRENE 83 



PART II. 
SUEGICAL DISEASES. 



CHAPTER VI. 

ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS ... 91 

By Roswell, Park, M. D. 

10 



CONTENTS. 11 

CHAPTER VII. 

PAGE 

THE SURGICAL FEVERS AND SEPTIC INFECTIONS 97 

By Roswell Park, M. D. 

CHAPTER VIII. 

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 

ANIMALS 114 

By Roswell Paek, M. D. 

CHAPTER IX. 

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 

ANIMALS (Continued) 130 

By Roswell Paek, M. D. 

CHAPTER X. 

SYPHILIS 145 

By John A. Fobdyce, M. D. 

CHAPTER XI. 

GONORRHOEA AND ITS SEQUELS 171 

By William T. Belfield, M. D. 

CHAPTER XII. 

SHOCK AND COLLAPSE 185 

By Roswell Park, M. D. 

CHAPTER XIII. 

SCURVY AND RICKETS 188 

By Roswell Paek, M. D. 

CHAPTER XIV. 

SURGICAL ASPECTS AND SEQUELAE OF OTHER INFECTIONS AND 

DISEASES 192 

By Roswell Paek, M. D. 

CHAPTER XV. 

POISONING BY ANIMALS AND PLANTS 198 

By Roswell Paek, M. D. 

CHAPTER XVI. 

ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS .... 202 
By Roswell Paek, M. D. 



12 CONTENTS. 

PART III. 

SURGICAL PRINCIPLES AND METHODS AND MINOR 

PROCEDURES. 



CHAPTER XVII. 

PAGE 

CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; PARA- 
CENTESIS; COUNTER-IRRITATION 207 

By John Pabmenteb, M. D. 

CHAPTER XVIII. 

MINOR SURGERY AND BANDAGING 215 

By John Parmenteb, M. D. 

CHAPTER XIX. 

ANAESTHESIA AND ANAESTHETICS 230 

By Hobaet Amory Habe, M. D. 

CHAPTER XX. 

SURGICAL DIAGNOSIS 245 

By Chauncey P. Smith, M. D. 



PART IV. 
INJURY AND REPAIR. 

CHAPTER XXI. 

WOUNDS 257 

By Chables B. Nancbede, M. D. 

CHAPTER XXII. 

GUNSHOT WOUNDS 264 

By Charles B. Nancbede, M. D. 

CHAPTER XXIII. 

PROCESS OF REPAIR 284 

By Chables B. Nancbede, M. D. 

CHAPTER XXIV. 

TREATMENT OF WOUNDS; ANTISEPSIS AND ASEPSIS 292 

By Chables B. Nancrede, M. D. 



CONTENTS. 13 



PART V. 



SURGICAL AFFECTIONS OF THE TISSUES AND 
TISSUE-SYSTEMS. 



CHAPTER XXV. 

PAGE 

CYSTS AND TUMOES 305 

By Roswell Park, M. D. 

CHAPTER XXVI. 

SUKGICAL DISEASES OF THE SKIN 356 

By William A. Hard a way, M. D. 

CHAPTER XXVII. 

BURNS, SCALDS, AND FEOST-BITES, AND THEIR TREATMENT . . 378 
By John Parmenter, M. D. 

CHAPTER XXVIII. 

THE MUSCLES, TENDONS, 'AND TENDON-SHEATHS, BURSAS, AND 

FASCIA 385 

By Herbert L. Burrell, M. D. 

CHAPTER XXIX. 

INJURIES AND DISEASES OF THE LYMPHATIC VESSELS AND 

NODES 407 

By Frederic Henry Gerrish, M. D. 

CHAPTER XXX. 

SURGICAL INJURIES AND DISEASES OF THE VEINS 426 

By James M. Holloway, M. D. 

CHAPTER XXXI. 

SURGICAL INJURIES AND DISEASES OF THE ARTERIES, IN- 
CLUDING ANEURISM 433 

By Duncan Eve, M. D. 

CHAPTER XXXII. 

INJURIES AND DISEASES OF THE JOINTS AND JOINT-STRUC- 
TURES . . 463 

By Joseph Ransohoff, M. D. 

CHAPTER XXXIII. 

OPERATIONS ON JOINTS 500 

By Joseph Ransohoff, M. D. 



14 CONTENTS. 

CHAPTER XXXIV. 

SURGICAL DISEASES OF THE OSSEOUS SYSTEMi/; V .* • 
By Bos well Park; -^.Tx 



FEACTUEES 



DISLOCATIONS 



CHAPTEB XXXV. 
By Henry H. Mudd, M- D. 

CHAPTEB XXXVI. 
By Henry H. Mudd, M.D. 



PAGE 
'512 



545 



597 



PAET VI. 
SPECIAL OR REGIONAL SURGERY. 



CHAPTEB XXXVII. 

SURGICAL DISEASES AND INJUEIES OF THE HEAD 621 

By Roswell Park, M.D. 

CHAPTEB XXXVIII. 

SUEGICAL DISEASES AND INJUEIES OF THE SPINE 672 

By Edward H. Bradford, M.D. 

CHAPTEB XXXIX. 

SURGICAL DISEASES AND INJUEIES OF THE HEAET AND PERI- 
CARDIUM, WITH SUEGEEY OF THE LARGE BLOODVESSELS; 

LIGATIONS 707 

By Duncan Eve, M.D. 

CHAPTEB XL. 

SURGICAL DISEASES AND INJURIES OF THE RESPIRATORY 

ORGANS 730 

By D. Bryson Delavan, M.D. 

CHAPTEB XLI. 

SURGICAL DISEASES AND INJURIES OF THE FACE 764 

By Edmond Souchon, M. D. 

CHAPTEB XLII. 

SURGICAL DISEASES AND INJURIES OF THE NECK 784 

By Edmond Souchon, M. D. 



CONTENTS. 15 

CHAPTER XLIII. 

PAGE 

SURGERY OF THE CHEST 805 

By Frederic S. Dennis, M. D. 

CHAPTER XLIV. 

SUEGICAL DISEASES AND INJURIES OF THE MOUTH, TONGUE, 

TEETH, AND JAWS 849 

By Arthur Dean Bevan, M. D. 

CHAPTER XLV. 

SURGERY OF THE ABDOMEN 872 

By Maurice H. Richardson, M. D., assisted by Farrar 
Cobb, M.D. 

CHAPTER XLVI. 

HERNIA 930 

By Maurice H. Richardson, M.D. 

CHAPTER XLVII. 

DISEASES OF THE RECTUM AND SIGMOID FLEXURE 952 

By Charles B. Kelsey, M. D. 

CHAPTER XL VIII. 

GENITO-URINARY SURGERY 970 

By William T. Belfield, M. D. 

CHAPTER XLIX. 

CHANCROID, OR VENEREAL ULCER 1023 

By Roswell Park, M. D. 

CHAPTER L. 

SURGICAL DISEASES AND INJURIES OF THE FEMALE REPRO- 
DUCTIVE ORGANS 1026 

By James H. Etheridge, M.D. 

CHAPTER LI. 

SURGICAL DISEASES AND INJURIES OF THE BREAST 1061 

By Charles B. Parker, M.D. 

CHAPTER LII. 

AMPUTATIONS 1079 

By Rudolph Matas, M.D. 

CHAPTER LIII. 

ORTHOPAEDIC SURGERY 1108 

By Robert W. Lovett, M.D. 



16 CONTENTS. 

CHAPTER LIV. 

PAGE 

PLASTIC SURGERY 1154 

By Aepad G. Geestbb, M. D. 

CHAPTER LV. 

THE SURGICAL DISEASES AND INJURIES OF THE EYE AND 

ORBIT 1167 

By Charles Stedman Bull, M. D. 

CHAPTER LVI. 

SURGICAL DISEASES AND INJURIES OF THE EAR 1200 

By Clarence J. Blake, M. D. 

CHAPTER LVII. 

ON SKIAGRAPHY, OR THE APPLICATION OF THE RONTGEN 

RAYS TO SURGERY 1212 

By Roswell Park;, M. D. 



GENERAL SURGERY. 



PART I. 
SURGICAL PATHOLOGY. 



CHAPTER I. 

HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 

By Roswell Park, M. D. 

The reactionary results of injury to various tissues and the first 
local appearances due to the surgical infectious diseases are indicated 
by certain appearances which, for a few hours at least, are in large 
measure common to both. Their beginnings being pathologically 
similar, their results depend not alone on the violence or intensity of 
the process, but in predominating measure upon the primary influ- 
ences at work. The consequences of mere mechanical injury — such 
as strain, laceration, etc. — are in healthy individuals promptly repaired 
by processes which will be taken into consideration in the ensuing 
chapters. They are throughout conservative and reparative, and are 
directed toward restoring, so far as possible, the original condition. 
The consequences, on the other hand, of the surgical infections are 
more or less disastrous from the outset, although the extent of the 
disaster may be localized within a very small area, as after a trifling 
furuncle, or they may be so widespread as to disable a limb or an 
organ, or they may even be fatal. It is of the greatest importance, 
not alone for scientific reasons, but because treatment must in large 
measure depend upon the underlying conditions, to differentiate 
between these two general classes of disturbance, which we speak of 
as — 

A. Those produced by external or extrinsic disturbances — /. e. 
traumatisms, sprains, lacerations, etc. ; and 

B. Those produced by internal and intrinsic causes, which, for the 
most part, are the now well-known micro-organisms, such as produce 
the various surgical diseases. 

These latter disturbances may be imitated or simulated in the 
presence of certain irritants within the tissues, such as the poisons of 
various insects and plants ; the irritation produced by foreign bodies, 

2 17 



18 SURGICAL PATHOLOGY. 

minute or large ; and possibly the presence within the system of cer- 
tain poisons whose nature is not yet known, such as that of syphilis 
or certain others whose chemistry is fairly well understood, but whose 
presence cannot be easily explained, as uric acid, etc. 

Clinically, all these disturbances are manifested by certain phe- 
nomena common to each which may present themselves at one time 
more prominently, at another time less so. These significant appear- 
ances have been recognized from time immemorial as the color, rubor, 
dolor, tumor, et fuiietio Icesa of our ancestors, or as the heat, redness, 
pain, swelling, and loss of function of our common experience. When 
one or more of these are present, the surgeon cannot afford to disre- 
gard the fact, while he should, moreover, be able to account for each 
on general principles which should to him be well known. 

To their more exact study we must, however, make some preface 
in the way of general remarks concerning a phenomenon everywhere 
easily recognized, but as yet incompletely understood. This phenom- 
enon has reference to an undue supply of blood to a part, and is com- 
monly known under two terms which are practically synonymous — 
namely, congestion aud hyperemia. To begin with these, then, we 
must note, first of all, that congestion and hyperemia may be — 

A. Active; and 

B. Passive. 

They may also be spoken of as — 

1. Acute; and 

2. Chronic. 

Considering first the two latter distinctions, it will be found that 
the acute hyperemias are met with most often in consequence of sharp 
mechanical disturbances. The chronic hyperemias, on the contrary, 
are conditions which in many individuals are more or less permanent. 
Note accurately here the proper significance of certain terms. Hyper- 
semia means, in effect, an over-supply of blood to the given part : the 
term should have only a local significance. When the entire body 
seems to be too well supplied with blood, the condition is known as 
plethora, the counterpart of which term is usually anaemia. The direct 
counterpart of the term hyperamia should perhaps be ischamia, mean- 
ing a perverted blood-supply in reduced amount. With plethora and 
anemia as terms implying general conditions, with hyperemia and 
ischemia implying local conditions, there should be little room for 
confusion in phraseology. 

The active form of hyperemia used to be called " fluxion," a term 
now rarely used. Active hyperemia means an increased supply of 
arterial blood. In passive hyperemia the over-supply is rather of 
venom blood. In the former case the condition seems due to over- 
activity of the heart, with such local tissue-changes as permit it to 
occur. In passive hyperemia the blood-current is slower — there is a 
tendency toward, and sometimes there is actual, stagnation ; all of 
Avhich is usually due to obstruction to the return of blood' to the 
heart. The conditions permitting these two results may be widely 
variant. 

Active hyperemia may be produced by purely nervous influences 
even those of emotional origin. The flushing of the face which is 



HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 19 

known as " blushing " is, perhaps, the most common illustration of 
this fact. It is well known also that this is, in some degree at least, 
the result of division of certain nerves which have to do with the 
regulation of the blood-supply. The cervical sympathetic is the best 
known and most often studied of these, and the consequences of 
division of this nerve in the neck are stated in all the text-books on 
physiology. So also by electrical stimulation of certain nerves the 
parts supplied by them can be made to show a very active hyperemia, 
which will subside shortly after discontinuance of stimulation, provid- 
ing this has not been kept up too long. In active hyperemia there 
is absolute increase of intra-arterial tension, and under these circum- 
stances pulsation may be noted in those small vessels where commonly 
it is not seen nor felt. This is the explanation of the throbbing pain 
complained of under many actively hypersemic conditions. This 
hyperffimia affords the explanation of the clinical signs to which 
attention has already been called. The increased heat of the part is 
the result of greater access of blood, which prevents cooling by 
radiation and evaporation : the peculiar redness is due to the greater 
filling of the capillaries with the blood, which gives the peculiar hue 
to the skin and visible textures ; while to the increased pressure upon 
sensory nerves is also due the pain. The minuter changes occurring 
within the congested part call for more accurate description. "Whether 
or not there be actual dilatation of capillaries under these circumstances 
is a matter still under dispute, but of the dilatation of the larger vessels 
there can be no possible question. 

As hypersemia is to such a great extent brought about by action of 
the nervous system, it is well to divide it more accurately into the 
hypersemia of paralysis, or neuroparalytic congestion, which is the result 
of a paralysis of the constrictor fibres of the vasomotor system, and 
into the hypersemia of irritation, or neurotonic congestion, which is due 
to the irritation of the dilators (Recklinghausen). Physiologists are 
fairly well agreed that as between the dilating and the constricting 
apparatus of the vasomotor system there is ordinarily preserved a cer- 
tain degree of equilibrium ; to which fact it is probably due that a 
normal condition of affairs is brought about after temporary disturb- 
ance, since, too, over-action in one direction succeeds reaction in the 
other. As Warren has illustrated this, our common treatment of frost- 
bite by cold applications is a concession to this fact, since by the cold 
application we endeavor to limit the reaction which would otherwise 
follow after thawing out the frozen part. 

The best examples of the hypereemia of paralysis are perhaps to be 
met with after certain injuries to nerves, as, for instance, flushing of 
the face and hypersecretion of nasal mucus, tears, etc. after injury to 
the cervical sympathetic. Such too, in its essentials, is that form of 
shock known as brain-concussion, which is often followed by nutri- 
tive disturbances among the brain-cells, with consequent perversion 
of brain-function. 

Waller's experiment of placing a freezing mixture over the ulnar nerve 
at the back of the elbow is also significant, the result being congestion and 
elevation of surface temperature of the fingers supplied by this nerve. Con- 
gestion and swelling have also been observed after fracture of the internal 



20 SURGICAL PATHOLOGY. 

condyle of the humerus, bv which this nerve was pressed upon ; and similar 
phenomena may be noted 'in fingers or toes as the result of injuries of other 
nerves. 

Hvpersemia due to paralysis of the perivascular ganglia is observed 
sometimes in transplanted flaps, in the suffusion of a limb after re- 
moval of the Esmarch bandage, in the congestions of certain sac- 
walls after tapping, in the hvpersemia, perhaps even hemorrhage, from 
the bladder-wall after too 'quickly relieving its over-distention, in 
the swelling of the extremities when they begin to be first used after 
having been put at rest because of injury, etc. 

The hypercemias of dilatation are more acute in course and mani- 
festation. Along with them go sharp pain, hypersecretion of glands, 
cedema, and sometimes desquamation of superficial parts. The facial 
blush due to effusion ; the temporary flushing due to indulgence in 
alcohol ; the suffusion of the conjunctiva, perhaps the face, with 
hyperlachrvmation, accompanying facial neuralgia or heniicrania; and 
the hyperseruia consequent upon herpes zoster, urticaria, etc., are 
illustrative examples of this form. The erythema due to nerve irri- 
tation or injury, the swelling of the joints which appears after similar 
lesions, and that condition described by Mitchell as erythromelalgia, 
probably also belong here. In fact, almost all the reflex hyper- 
aemias are hypersemias of dilatation. 

The forms of hypersemia considered above belong mainly to the 
designation of active. Passive hyperaemia is most often a mechani- 
cal consequence of obstruction to return of blood which can be imitated 
at will, and which is not infrequently the result of sheer carelessness, 
as when an injured limb is bandaged too tightly. Experiment shows 
that when such mechanical obstruction has taken place there is tempo- 
rary increase of intravenous pressure, which soon returns to the nor- 
mal standard, such readjustment meaning that blood has found its way 
back by collateral circulation. Only when such rearrangement is pos- 
sible do we have anything like permanent passive hypersemia. In 
organs with a single vein, such as the kidneys, the question of obstruc- 
tion may assume a very important aspect. Under these circumstances 
the appearance of the involved part, when visible, is spoken of as 
cyanotic, while its surface instead of being abnormally warm is the 
reverse, due to impeded access of warm blood and more rapid surface- 
cooling. The blood under such conditions is often darker than natural, 
because, remaining longer in the part, it absorbs more carbonic dioxide 
or at least gives up more of its oxygen. So long as actual gangrene 
is in it threatened, the blood-column has a communicated pulsation, at 
least in the large veins. Escape of corpuscular elements may occur 
after the phenomena above noted have been present for some' time • 
but the corpuscles rarely, if ever, escape until there has been more or 
less copious transudation of the fluid portion of the blood — i. e. the 
serum. When anatomical changes can be grossly yet carefully observed 
as in the fundus of the eye, it is seen that under these circumstances 
the arteries become smaller, although whether this be a primary or 
secondary change is not to be made out. Discoloration of the integu- 
ment is the frequent result of leakage of blood-corpuscles and their 
pigmentary substance into the tissues, and is consequently a frequent 



HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 21 

accompaniment of chronic passive oedema. It is seen very often in 
connection with varicose veins of the legs. 

Another form of passive congestion or hyperemia is that due to 
enfeeblement of the heart's action by serious injury or wasting disease. 
When under these circumstances the lung has become more or less 
infiltrated with fluid, with hemorrhagic extravasation, the condition is 
known as hypostatic pneumonia — a misnomer, nevertheless indicating 
a condition which is only too frequent in the aged and feeble. 

Results op Hyperemia and Congestion. 
These may be — 

1. Speedy Subsidence of all Hypersemic Phenomena — Resolution. 

2. Acute Swelling. 

3. Chronic Enlargement. 

4. Gangrene. 

5. Nutritional Changes — Atrophy and Hypertrophy. 

1. The speedy subsidence of hypersemic phenomena is often 
known as resolution — a term which has also been applied to the retro- 
grade phenomena after a genuine inflammation. For present purposes 
it implies, first, the subsidence into inactivity of the exciting cause or 
its complete removal. This may include the passing of an emotion, 
the removal of an irritant, the loosening of a bandage, the resort to 
certain applications or to constringing or astringing measures by which 
the effect is counteracted. A particle of dust in the conjunctiva may 
within a very few moments produce a very active congestion of the 
conjunctival vessels, which, ordinarily scarcely visible, become now 
prominent and easily noted. The removal of the offending substance 
permits a prompt return to their original size, and all this may be a 
matter of perhaps half an hour. This is an example of the speedy 
subsidence of the hypersemia of dilatation after removal of the cause. 
Should the hypersemia not subside at once, it is well known what 
aid may be gathered from cold applications, or in this instance 
from some gentle astringent collyrium, or from some agent whose 
physiological effect it is to produce vascular contraction — cocaine, 
adrenal extract. 

2. Acute Swelling. — When the effusion above referred to takes 
place into loose connective tissues the condition is spoken of techni- 
cally as oedema, while Avhen it occurs into a previously existing cav- 
ity, such as that of a joint, it is known as an effusion. The amount 
of blood thus effused will be in large degree influenced by the anatom- 
ical and mechanical conditions obtaining about the part. It may be 
laid down as a general rule that when the extravascular pressure 
equals the intravascular pressure little or no more fluid may escape. 
As a matter of fact, it is seldom that the former even rises to the 
degree of the latter. Conversely, one method of treating such 
cedemas and effusions is by some device which shall make the ex- 
travascular pressure exceed the intravascular, when the fluid is, as 
it were, forced back into the vessels, and is made to resume its 
proper place within the same. This is often done by taking advan- 
tage of elastic compression, as when a rubber bandage is applied 
about the part. In certain parts of the body it may be done by 



22 SURGICAL PATHOLOGY. 

pressure brought about by some other device. Pressure may be 
used practically for two purposes : 

A. To so increase extravascular pressure as to limit the possible 
amount of an effusion, as when it is put on early after an injury ; or, 

B. When it is used as a later resort for the purpose of reducing 
swelling which has already occurred. 

3. Chronic Swelling. — This is something more than the swelling 
alluded to under Acute Swelling. Chronic swelling implies either a 
continuous passive hyperemia, or, what is much more common, a 
positive increase in tissue-elements as the result of an over-supply of 
nutrition brought by the blood, which itself was furnished to the part 
in a degree far in excess of its needs. The result is a more rapid 
reproduction of cell-elements, with result in the shape of tissue-thick- 
enings or tissue-enlargements, which are to the laity known as " over- 
growth," or to us as hypertrophy, or, more properly speaking, hyper- 
plasia, of a part. This chronic swelling or chronic enlargement is in 
some degree also connected with the phenomena of escape of white 
corpuscles from the blood-vessels and mitotic division of certain tis- 
sue-cells, which have up to this time been usually regarded as so dis- 
tinctive a feature of the true inflammatory process. 

4. Gangrene. — This may be the result of sheer hypersemia — for 
the most part the passive forms — though most instances of gangrene 
due to intrinsic causes are inseparable from the presence of infectious 
micro-organisms. The gangrene which is spoken of here would 
include that due to the pressure of tumors, tight dressings, or any 
natural or intrinsic agency, and that due to pressure from without 
when not so pronounced as to produce immediate and total loss of 
circulation in a part. It includes the formation of many bed-sores 
and so-called pressure-sores, which may be due to an enfeebled heart, 
to an obstructed pulmonary circulation, or to external pressure in con- 
junction with cardiac debility. While insisting, then, that gangrene 
be recognized in this place as a possible result of hypersemia, it should 
be added that gangrene is in effect a tissue-death, and that dead tissue 
is always and everywhere practically the same thing, no matter by 
what causes brought about. Consequently, the subject of gangrene 
will be considered under a heading by itself. 

5. Nutritional changes will be considered by themselves a little 
later. 

The consequence of persistent hypervemia is exudation — i. e. escape 
of blood-plasma from the vessels into body-cavities and tissue-interspaces. 
This leads to consideration under a distinct heading of 

Exudates. 

Exudation may occur alike in vascular and non-vascular, in firm 
and soft tissues, in, under, and upon membranes. With respect to 
location, exudates are described as/ree when found upon free surfaces 
or within natural cavities ; interstitial when found between the tissues 
or parts of tissues ; and parenchymatous when they are situated with- 
in the tissues themselves, particularly in epitheliafand glandular cells 
of any kind. 

As concerns quality, exudates are serous, mucous, fibrinous, or 



. . HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 23 

mixed, the mixed forms including the so-called aero-purulent, the 
muco-purulent , the croupous, and the diphtheritic, as they used to be 
mentioned by the older writers. When any exudate contains red 
globules in sufficient quantity to stain it, it is called hemorrhagic. 

Serous exudates from free surfaces are sometimes spoken of as 
serous catarrhs ; when into cavities, as dropsies ; when into tissues, as 
oedema; when occurring beneath the epidermis they form serous vesi- 
cles or blebs or bullae. 

Fibrinous exudation refers to the fluid which coagulates soon after 
its exit from the vessels within those spaces into which it has oozed. 
When flocculi of coagula float in serous fluid it is known as a sero- 
fibrinous exudate. Pure fibrinous exudate occurs relatively rarely, 
save in and upon mucous membranes. The extent to which exposure 
to the air is responsible for the firm coagulation of the fibrin pre- 
viously held in solution is uncertain. The most potent factors in pro- 
ducing such coagulation are bacteria, but it is not yet disproven that 
coagulation may occur without their aid. When such coagulation 
occurs upon the surface of a mucous membrane it has been spoken of 
as croupous. When the epithelial covering as well as the basement 
membrane, and often the submucous tissues, are involved so that now 
the membrane cannot be stripped off without tearing across minute 
blood-vessels, the exudate has been known as diphtheritic. These 
terms may possibly be still retained in an adjective sense as implying 
the exact location of a surface exudate, but are scarcely to be used in 
any other significance. 

The following table illustrates significant differences whose full 
importance cannot be impressed before a study of inflammation has 
been carefully entered upon : 

Hyper^emic Exudates. Inflammatory Exudates. 

Poor in albumen. Rich in albumen. 

Rarely coagulate in the tissues. Usually coagulate in the tissues. 
Contain few cells. Contain numerous cells. 

Low specific gravity. High specific gravity. 

Contain no peptone. Contain peptone (product ji 

cell-disintegration). 

Treatment of Congestion and Hyperemia. 

These disturbances are to be combated, first of all, by insisting 
upon physiological rest. This, perhaps, is the most important meas- 
ure of all. The profession is greatly indebted to Hilton for the 
decided advance which he made in the treatment of congestive and 
inflammatory affections by insisting upon this principle in his cele- 
brated work on Rest and Pain, which every young practitioner should 
read. Aside from this first and underlying principle, the treatment 
must, in some measure at least, be based upon the time at which 
we are called upon to treat the case. If seen at once, before exu- 
dation has been excessive or the other disturbances marked, we may 
carry out a certain line of treatment for the purpose of limiting all 
these unpleasant features. On the other hand, if seen late, when 



24 SURGICAL PATHOLOGY. 

exudation has been copious and when pain and other disturbances are 
due to its presence, a distinctly different course will be adopted. 

Toward the end first mentioned— namely, the limitation of hyperemia — we 
may adopt local and general measures. Local measures include graduated pres- 
sure, providing this be not intolerable to the patient, endeavoring to so equalize 
pressure that outside of the vessels it shall equal that inside. This may be done 
by careful bandaging, extreme care being taken that the pressure be applied 
from the very extremity of the limb ; otherwise, passive exudation might be 
augmented and gangrene be precipitated. Elevation of a limb will often accom- 
plish much the same purpose. Cold, which is in effect an astringent and which 
tends to contract blood-vessels, is another measure in the same direction, and if 
applied early will do much to limit the degree of the attack. This may be 
applied as dry or moist cold, and should be gradually mitigated as the congestion 
subsides. It acts through the vasomotor system, and is a measure to be resorted 
to with some caution. An efficient way of applying dry cold can be extempor- 
ized by a few yards of rubber tubing, held in place by wire or sewed in place 
to a piece of cloth, through which a stream or cold water is permitted to gently 
pass. 

Heat is another efficient means, acting, however, in a rather different way. 
Heat is a measure to be employed to hasten the disappearance of exudation — 
in other words, to quicken resorption, which it does by equalizing blood-pres- 
sure, dilating the capillaries, stimulating the lymphatic current, and in every 
way helping to clear the tissues of that which has left the blood-vessels. 

It is necessary also, at least in extreme oases, to employ some deter- 
gent or derivative measures, including blood-lettinr/, which is not suffi- 
ciently often resorted to. When done for this purpose, depletion should 
be carried out at the area involved if possible. This may be done 
either as venesection, by leeching either with the natural or the arti- 
ficial leech, or by a series of minute punctures or incisions, which give 
relief to tension, permit the rapid escape of fluid exudate, and often 
save tissues from the disastrous effects of strangulation. In some 
cases of deep-seated congestions these measures are inapplicable, and 
venesection at the point of election — say the cephalic vein in the arm 
— may be followed by great benefit. Another method of depletion is 
by administration of cathartics, such intestinal activity being stimu- 
lated as shall lead to copious watery evacuations. The salines rank 
high as measures directed toward this end, but in emergency much 
stronger and more drastic drugs may be administered, such as jalap, 
calomel, elaterium, etc. Diaphoretics and diuretics help to reduce 
temperature, and in some degree to deplete, but their action is usually 
slow. When exudation is considerable in amount and confined to some 
one of the body-cavities, it is often best combated, if at all obstinate, ' 
by the method of aspiration. This includes any suitable suction ap- 
paratus by which the fluid may be withdrawn through a small needle 
or cannula, the operation being trifling in difficulty, but one to be per- 
formed under strictest aseptic precautions, lest infection of an exudate 
already at hand be permitted. 

Certain individuals, especially the neurotic, will need more or less anodvne 
particularly when local applications fail to give relief. Sometimes a small dose 
of morphia administered hypodermically will act like magic in making efficient 
those measures which would otherwise be inefficient, in little children also 
some anodyne or hypnotic will be of great service. Under all circumstances it 
is well to beep the lower bowel empty, and certain elderly individuals with weak 
and enfeeb ed hearts will need the stimulation to be afforded by digitalis, quinine 
and alcohol, or preferably by strychnia administered subeutaneouslv 



HYPEREMIA: ITS CONSEQUENCES AND TREATMENT. 25 

In cases of chronic hypersemia and its consequent hyperplasias 
(induration, thickening, etc.) there is no one measure so generally 
applicable and effective as the continued use of cold-water dress- 
ings. These are generally spoken of as " cold wet packs," and may 
be continued — constantly or intermittently — for many days. 

On Atrophy and Hypertrophy, and the Consequences op 
Altered, Diminished, and Perverted Nutrition. 

As a consequence of increase of nutrition we have produced a con- 
dition known commonly as hypertrophy, more accurately as hyperpla- 
sia. Hypertrophy literally means overgrowth, whereas hyperplasia 
more accurately describes that which constitutes hypertrophy — 
namely, numerical increase of constituent cells. Common usage 
has made the more inaccurate name " hypertrophy " cover nearly 
all these conditions. Hypertrophy or hyperplasia means enlargement 
of a part or of an organ beyond its usual limits, and as the result 
of increased function or increased nutrition. It is to be distin- 
guished from gigantism, which means inordinate enlargement as 
the result of a congenital tendency or condition. Hypertrophy is — 



A Phvsioloaical i L Compensatory ; 

3 " \ Z. r rom deficient use. 



3. Local ; 
B. Pathological -l .' □ ., ' 

[_ 6. Congenital. 

A. Physiological Hypertrophy. — 1. This includes many of the 
compensatory enlargements of an organ or a part when extra work is 
put upon it owing to deficiency of some other organ or part. This is 
spoken of as compensatory enlargement. Illustrative examples may 
be seen in the heart, which becomes larger and stronger when the 
blood-vessel walls are diseased and their lumen marrowed or when 
other obstructions to circulation are brought about ; again, in enlarge- 
ment of one kidney after extirpation of the other, or of the wall of 
the stomach when the pylorus is constricted or obstructed ; again, of 
the fibula after weakening or more or less destruction of the tibia, or 
of the shaft of any bone when it has been weakened at some point 
by not too acute disease ; or, again, of the walls of bursse after con- 
stant friction. 

2. The best examples of physiological hypertrophy owing to defi- 
cient use are perhaps seen in some of the lower animals; as, for 
instance, in the teeth of such rodents as beavers when kept in cap- 
tivity and prevented from natural use. 

B. Pathological Hypertrophy. — 3, 4. Instances of this are every- 
where and every day to be met in the results of so-called chronic 
inflammation, a term which is a complete misnomer and should be 
expunged from text-book use. So-called chronic inflammation simply 
means increase of nutrition owing to a certain degree of hypersemia, 
which may have been produced in the first place as the result of trau- 
matism, which may come from chemical irritants circulating in the 
fluids of the part — as, for example, uric acid, etc. — or which are 



26 



SURGICAL PATHOLOGY. 



brought about as the result of perverted trophic-nerve influence. 
Instances of local pathological hypertrophy may be seen in the 
thickened periosteum after injury, in the enlargement of a phalanx 
known as the " baseball finger," and in numerous other places ; or 
they may be general, in which case they are brought about mainly 
by some irritating material in the general circulation. The unknown 
poison of syphilis notoriously provokes such nutritive disturbances. 

5. Senile hypertrophy is connected with nutritional disturbances 
characteristic of old age, as to whose remote causes we are still in the 
dark. Instances of senile hypertrophy, however, are common, par- 
ticularly in the prostates of "elderly men, which are quite prone to 
undergo vexatious, and even vicious, enlargement. 



Fig. 1. 




Congenital hypertrophy: gigantism of both lower extremities (case of Dr. Graefe [Sandusky]). 

6. Of congenital hypertrophy and that of unknown origin we see, 
for instance, examples in certain rare cases of hypertrophy of the 
breast, in leontiasis, perhaps even in acromegaly, etc.; and these are 
to be distinguished from gigantism, because in most instances of the 
former type the hypertrophic tendency is not manifested until youth 
or adult life, whereas gigantism is a condition in which the tendency 
was apparently manifested even before the birth of the individual. 

Atrophy. 

Atrophy implies impaired nutrition, and means diminution in the size 
of an organ or part, and is the converse of hypertrophy. It is neces- 
sary to make plain that in atrophy nutrition is only impaired and not 



HYPEREMIA .- ITS CONSEQUENCES AND TREATMENT. 27 

arrested, since complete arrest of nutrition means necrosis — i. e. gan- 
grene. It may be — 

( 1 . From Disuse without Disease ; 
A. Physiological < 2. Biological or Developmental ; 

(3. Senile. 

{4. Result of Acute Tissue-losses ; 
5. Result of Phagocytic Activity; 
b. Result ot Continuous Pressure ; 
7. Specific. 

A. Physiological Atrophy. — 1. This is always the result of 
disuse or impaired function from any cause. Its evidences are most 
quickly seen in the fatty structures and muscles — i. e. in the soft 
parts. It is true, however, even of the bones, or, of greater inter- 
est, even in the brain-cells. We see evidences of it also in minute 
organs ; as, for example, in the digestive glands in certain cases 
where diet is restricted. Again, we see it in the diminution of the 
size of the heart after hip -amputation, less being required of that 
organ. Again, in the entire structure of the rectum after colostomy. 

2. Examples of the developmental type are best seen in the natural 
disappearance of the hypogastric arteries, the ductus arteriosus, the 
vitelline duct, the Wolffian bodies, and in the various generative ducts 
(Gartner's, etc.) shortly after birth of the human individual. We see 
it also in the prostate after double brchidectomy. Equally illustrative 
is the disappearance of the tail and gills of the tadpole, the eyes of 
animals living in caverns, and, in a general way, of organs which 
become useless owing to a different environment. 

3. Senile atrophy is seen equally well in the hair-follicles, the teeth, 
the bones, and the sexual organs of elderly people — in fact, in all their 
tissues, even in the brain. 

B. Pathological Atrophy. — 4. Very acute atrophy of surrounding 
tissues is the necessary accompaniment of destruction by suppurative 
or other disturbances ; that is, parts disappear by absorption which 
have not been interfered with by pyogenic organisms. So complete 
may atrophy be under these circumstances as to cause disablement of 
an organ or part. This kind of senile disappearance is merely an 
expression of phagocytic activity, although not now a question of 
bacteria. 

5. The same is true of that variety spoken of above as biological 
or developmental, since phagocytes are the active agents in producing 
the disappearance of the tadpole's tail. 

6. A more slow form of pathological atrophy is seen in the gradual 
disappearance of tissues in the neighborhood of advancing tumors, 
enlarging cysts, etc. This is perhaps but another expression of atro- 
phy from continuous pressure. But a still better illustration is the 
atrophy which comes from immobilization of a part without pressure. 
This is notorious when splints or orthopaedic apparatus have to be long 
kept in place. 

7. Specific forms of pathological atrophy are largely connected with 
disturbances in the central nervous system. They are often spoken 
of as trophoneurotic. Their exact mechanism is not yet understood, 



28 SURGICAL PATHOLOGY. 

and cases may be confused under this head whose remote causes are 
widely different. Here should be included, for instance, the atrophy 
of a deep bone which occurs after extensive burn of the surface ; also 
that peculiar form of atrophy of tissues in the stump which produces 
the so-called conical stum}). These cases are indeed of a more com- 
plicated character, since if pressure be removed from the bone-end, 
especially in young people, the bone tends to grow faster than it 
should, while the soft parts disappear, partly as the result of mere 
disuse or loss of function. In this way conicity is produced, which 
sometimes calls for subsequent reamputation. Under this head might 
also be included the so-called " trophic inflammation " (misnomer) of 
some writers, such, for example, as ulceration of the cornea after 
division of the trigeminus. The general subject of atrophic elonga- 
tion also belongs here, referring to the fact that as a result of disuse, 
or sometimes of active disease, the bones, while showing atrophic 
changes in other respects, actually increase in length. Should such 
increase occur in one bone of those portions of the limbs which are 
supplied with two, the result would be posture-deformity and displace- 
ment of the terminal portion. 



CHAPTER II. 

SURGICAL PATHOLOGY OF THE BLOOD. 

By Roswell Park, M. D. 

The part played by the constituent elements of the blood in 
inflammation, suppuration, and other still more disastrous conditions 
is so great and so important that, before proceeding to discussion of 
these lesions, it seems necessary to set forth a resume of facts illus- 
trating the importance of accurate knowledge concerning this most 
important fluid. 

Thrombosis. 



\Z 



Thrombosis is a term applied to the formation of a thrombus — i. e. 
a clot within the cavity of the heart or one of the blood-vessels — the 
term being limited to coagulation of blood within these natural cavi- 
ties, and without specifying the exciting cause of the same. A clot 
so formed is called a thrombus. To be accurate, a distinction should 
be made between a thrombus, which is always caused before death — or, 
rather, during life — and the clot, which is essentially a post-mortem 
affair. Our application, then, of the terms " thrombosis " and 
" thrombus " refers solely to that which takes place during life. In 
order to appreciate the conditions which lead to thrombosis it is neces- 
sary to fully appreciate the reciprocal conditions which must normally 
be maintained between the circulating blood and the walls of the ves- 
sels in which it flows. Fluidity of blood depends always upon integ- 
rity of the vessel-wall. So long as its lining membrane be absolutely 
undisturbed and normal, blood will never coagulate within it, and the 
only thrombi that may be met within it are those which are propa- 
gated from a distance. Coagulation of blood is for the most part 
associated with the peculiar properties of fibrin. Fibrin, it is now 
well established, is produced by the union of two substances, known 
as fibrinogen and paraglobulin, which union takes place as the result 
of the activity of the so-called fibrin-ferment. The fibrinogen is 
ordinarily kept in solution in the blood-serum ; all of the fibrin-fer- 
ment, and at least the greater part of the paraglobulin, are contained 
within the colorless blood-corpuscles, by whose disintegration they 
are released. Consequently, so long as nothing happens to the leu- 
cocytes, coagulation cannot occur. It seems to be one of the peculiar 
activities of the endothelial lining of vessels to restrain this very dis- 
integration. Even when small quantities of fibrin-ferment are intro- 
duced from without, this membrane seems to have the power of ren- 
dering it inefficient, and large quantities introduced at once are 
necessary to artificially produce coagulation in this way. Physiolog- 
ical integrity of vascular walls, therefore, is inimical to thrombosis. 
Causes. — The underlying anise of all thrombi is, then, alteration 

29 



30 SURGICAL PATHOLOGY. 

of the endothelium. In consequence, when it is desirable to produce 
coagulation artificially advantage may be taken of this fact, and me- 
chanical injury to the vessel-walls may be quickly followed by the 
desired results. Advantage is also taken of this fact in surgery, espe- 
cially in certain methods of treating aneurism, by rude handling, by 
needling, by the introduction of horse-hairs, fine wires, etc. 

While such endothelial lesions are essential, there are, neverthe- 
less, numerous other accessory causes which must here be mentioned. 
These comprise — 

A. The presence of foreign bodies, as, for example, needles, hooklets 
of echinococci, parasites, particles of tumors, fragments from the 
heart- valves, and, most of all, that which is essentially a foreign body, 
a clot which has come from some other point. Around such foreign 
particles, by the way, will quickly group themselves a relatively large 
number of other leucocytes, affording thus another example of phago- 
cytosis, soon to be described. Mere slowing of blood-stream without 
some such mechanical irritation is not sufficient to produce coagulation. 
If, for instance, a section of vein be isolated between two ligatures, 
the ligation being aseptically done and the surroundings of the vein- 
wall disturbed as little as possible, the blood thus shut up within the 
vein remains fluid indefinitely. If, however, the vessel-wall be sepa- 
rated from its surroundings, so that its nourishment is compromised, 
the contained fluid quickly coagulates. 

B. Necrosis, gangrene, etc. lead to quick involvement of the endo- 
thelium of the vessels contained within the involved part, and conse- 
quently quickly to coagulation of the blood which they contain. 

C. Temperature has also an influence in the same direction, and 
extremes in either direction, or drying of vessels which may happen 
to be exposed to the air for some time, leads to the same results. 

D. Inflammatory and degenerative processes occurring in and about 
the vessel-walls tend always to produce coagulation. This is well 
seen in the influence exerted by the so-called atheromatous ulcers — i. e. 
the degeneration of certain areas in the walls of large vessels. 

E. Micro-organisms and their products are perhaps the most fre- 
quently effective of all the accessory causes of thrombosis. In other 
words, in all the surgical infectious diseases we may expect to find 
more or less, sometimes extensive, thrombosis in the vessels of the 
affected part. This may so far shut off circulation as to lead to gan- 
grene, which may be local or may terminate the life of the patient. 

Thrombi are classified as — 

1. Primary; and 

2. Propagated. 

The primary thrombus is one which has originated at the spot 
where it has been first produced, and is usually coextensive with its 
cause. ^ The propagated thrombus may be one which has been carried to 
a considerable distance, and is met with at a point widely different from 
that where it originated, or one which has extended along the vascular 
channel in which it was first formed, but far beyond the limits of its 
prime cause. "When a thrombus attaches itself to a part of the vessel- 
wall it is called parietal or valvular, because it does not completely 
occlude the vessel ; when it involves the entire circumference of the 



SURGICAL PATHOLOGY OF THE BLOOD. 31 

vessel, but does not completely occlude it, it is spoken of as annular. 
The obstructive thrombus is that which completely fills a given vessel 
and shuts off all circulation through it. 

The propagated thrombus extends usually in both directions, and 
always much farther in veins than in arteries. Thus, thrombi may be met 
with extending from the ankles even into the inferior vena cava. The 
venous valves, which, on the one hand, may excite coagulation, on the 
other hand tend to fix the coagula more firmly in their place. In arte- 
ries thrombi usually extend finally to the first collateral channel on 
the cardiac side, but occasionally they extend farther. The cause of 
a primary thrombus is to be sought for at the site of its lodgement ; the 
cause of propagated thrombi is often to be met with at wide distance 
from the effect. 

Thrombosis is, again, to be spoken of as — 

a. Marasmic ; 

b. Mechanical or traumatic ; 

c. Infective. 

a. The marasmic forms are due to essential alterations in the constituents of 
the blood, which for the most part are due to starvation or wasting disease. 
Marasmic thrombi seldom give rise to serious disturbance during life until the 
condition is so complex and serious that the patient is at death's door. Post- 
mortem evidences of marasmic thrombi, however, are often found, and yet have 
but little surgical significance. They are seen perhaps as often in the cranial 
sinuses as anywhere. 

b. Thrombi of mechanical or traumatic origin are those, for instance, which 
are due to the presence of foreign bodies, to stagnation of blood as the result of 
ischsemia or local anaemia, to compression by tumors, etc. 

c. Infective thrombi are those distinctly due to the injurious effects of micro- 
organisms, and are those mainly concerned in the various manifestations of 
sepsis which are of such interest to surgeons. ( Vide Plate II. Fig. 2.) 

While the ordinary evidences of thrombosis are most often looked 
for in the veins of the extremities, in the lungs, and in the cranial 
sinuses, it must not be forgotten that thrombosis may occur equally 
easily in the portal system of vessels ; in which case we find the most 
marked expressions in this system and in the liver. In cases also of 
pysemia proceeding from lesions in the rectum or in the bowels we get 
our first evidences of infection, abscess, etc., in the liver, and not in 
the lungs, to which point infective thrombi from other sources are 
promptly carried. 

Thrombi also pass through certain metamorphoses which must be 
mentioned : 

A. Decolorization. — This is noted particularly in the red thrombi, 
and is due to disintegration of the red corpuscles, their coloring mat- 
ter being diffused and resorbed or transformed into hsematoidin. It 
would be a mistake, however, to suppose that all light-colored thrombi 
are those which, originally red, have been decolorized. The possi- 
bility of white thrombi must be always remembered. 

B. Organization. — This is the result of time, and means a meta- 
morphosis into solid vascular connective tissue. Newly-formed 
minute vascular loops project from the vasa vasorum into the throm- 
bus, and it becomes thus vascularized, while the completion of the 
organization is due, for the most part, to spindle-celled connective 
tissue, which is formed by wandering cells that penetrate into the 



32 SURGICAL PATHOLOGY. 

thrombus from without. This gives the organized thrombus a certain 
resemblance to a sponge, and makes the original vein resemble a 
cranial sinus, since its interior is spanned by bands of connective 
tissue. Typical illustrations of this kind are seen, for instance, where 
the iliac veins join to form the inferior cava, by which a certain 
amount of obstruction to venous return is produced without its being 
total. The length of time required for these changes is indefinite. 
They begin, however, within a short time after ligature of a vein, and 
proceed with a rapidity varying according to circumstances. 

Fig. 2. 







Organization of thrombus (Letulle) : w, vasa vasorum still open ; m, media rich in muscle- 
cells; I, intima; /, fibro-vascular tissue; nc, new capillaries; nv, new arterioles. 

C. Calcification. — Calcium salts are occasionally deposited in 
thrombi, usually not until they have undergone considerable contrac- 
tion and alteration ; as the result of which we have formation of 
small masses, essentially minute calculi, to which the name of phlebo- 
liths has been given. These phleboliths are not infrequently found in 
more or less occluded and much distended varicose veins of the ex- 
tremities. Their formation is favorable in this regard, that they pro- 
hibit the occurrence of softening. 

D. Softening. — This is the most serious termination of the throm- 
botic accident, and is, for the most part, due to the agency of infecting 
organisms. A non-infectious form is, however, recognized, bv which 
there is a metamorphosis of original clot into an oily or pulpy fluid 
usually dark colored, but in the white thrombi often yellowish-white 
reminding one crudely of pus. The discovery of such material under 
these circumstances has led in time past to the supposition that pus, 
as such, was found floating in the blood — a condition that does not 
exist under any except most extraordinary circumstances. It is with 
infection of thrombi and consequent softening, however, that surgeons 
have most to deal, and the paramount importance to them of such 
disturbances is emphasized in those pages dealing with pyemia. 



SURGICAL PATHOLOGY OF THE BLOOD. 33 

A closely-allied topic to that above considered is the subject of 
thrombophlebitis. This means, in effect, inflammation of one or 
more veins, which is directly due to the presence therein of thrombi. 
Such a condition is, in its strict sense, an inflammation, since it is 
always an infectious process. If in the veins of a non-infected region 
simple thrombi form, they may be occluded by organization of the 
included masses, but such a process never extends beyond the imme- 
diate area involved. On the other hand, if the process be essentially 
an infectious one, either from without or from within, then both ves- 
sel and its contained thrombi succumb completely to the infectious 
process, which is also essentially a spreading one ; and this is limited 
only by mechanical barriers, by conservative suppuration, or often 
only by the life of the individual. Excellent examples of thrombo- 
phlebitis are seen in the involved uterine sinuses in cases of puerperal 
septicaemia, and in the cranial sinuses after infected compound frac- 
tures, or particularly after disease originating in the middle ear has 
extended to them. 

Thrombo-phlebitis is essentially a surgical condition, terminating 
favorably occasionally by suppuration and spontaneous evacuation, 
but calling loudly for surgical intervention whenever it can be recog- 
nized and the parts are accessible. The principles of treatment of 
these conditions are positive and unmistakable. They comprise 
evacuation of the infective material and disinfection of the involved 
cavities and tissues. Thus, in sinus-phlebitis — i. e., thrombo-phlebitis 
of the lateral sinus — it has been made practicable not only to open 
the sinus in the mastoid region, but to expose the jugular vein in the 
neck, to ligate it, and to wash through from one opening to the other, 
effectually getting rid in this way of a long mass of infected throm- 
bus. By such bold and radical measures only may life be saved in 
many of these instances. 



\/ Embolism. 



Embolism means the transportation of any material by ichich a 
blood-vessel can be occluded or plugged, from some one point in the 
vascular system to some other point. The underlying idea is that of 
transportation or carriage. An embolus is anything so transported, 
without implying its exact character. The name is even applied to 
so insubstantial an affair as a minute bubble of air, which, however, 
in a tube containing a circulating fluid is a possible source of consid- 
erable disturbance. A single bubble thus carried would, by itself, be a 
trifling affair, but when numerous bubbles are thus transported the 
result is such local disturbance as may lead to loss of function. 
Thus, air-embolism, so called, may provoke profound, even fatal, 
disturbances, as, when with the returning blood-stream through the 
cranial sinuses or one of the large veins in the neck when opened by 
accident or operation, air is sucked in, it is carried to the right side of 
the heart, whose action is perhaps completely perverted because of the 
new and strange substance which thus enters it, so different from that 
for which its lining membrane is prepared and to which it reacts. The 
entrance of air into veins, which constitutes in effect air-embolism, has 

3 



34 SURGICAL PATHOLOGY. 

been in time past a bugbear to surgeons, but nevertheless is a source 
of probable danger when large venous trunks in proximity to the heart 
are thus exposed. Air-embolism is certainly a rarity. On the other 
hand, those substances which figure most often as emboli are vegeta- 
tions from the valves of the heart; drops of fat; fragments of tumors; 
pieces of softened and disintegrated thrombi ; foreign bodies, as hooklets 
of echinococcus cysts ; and, perhaps most often of all, the micro-or- 
ganisms clinging to some minute fragment of thrombus which has 
been dislodged. Embolism is also produced experimentally by the 
artificial introduction into the circulating blood of cinnabar or small 
particles of pith or other material. Emboli differ in number ac- 
smallest appreciable up to the largest, which may be met with in the 
larger venous trunks. They are dislodged from their primary site 
sometimes by accident, as by rude manipulation, injury, etc.; some- 
times by undue cardiac activity, as when detached from a valve-wall ; 
sometimes by the process of softening of thrombus and a subsequent 
introduction into the blood-stream as a result of some trifling motion ; 
or even by spon tan eous processes. Emboli also differ in numbers ac- 
cording to the nature of the primary lesion. In cases of so-called 
fat-embolism fluidified fat is taken into the returning blood-stream, 
carried to the heart, churned up with the contained blood, and distrib- 
uted to the lungs in such a way that myriads of minute fat-masses 
are distributed throughout the capillaries of the lungs, and free circu- 
lation of blood through them thereby impeded. 

It will thus be seen that the relations between thrombosis and 
embolism are most intimate, but that either one may occur without 
the occurrence of the other. 

Among the viscera, with the exception possibly of the brain, no- 
where are the disastrous consequences of such processes as those just 
described more apparent and indicative than in thrombosis and embol- 
ism of the mesenteric blood-vessels — a condition not so rare as journal 
articles would imply, yet nevertheless one seldom recognized either 
during life or after death. Its principal symptoms consist of intense 
abdominal pain, bloody diarrhoea, subnormal temperature, sometimes 
with vomiting, perhaps in the latter stages vomiting of blood. Shock 
is usually also extremely marked. The consequence of this condition 
is almost inevitably gangrene of the intestine supplied by that particu- 
lar portion of the mesenteric vessels. The pain comes on within a 
short time after the occurrence, and under the peculiar circumstances 
gangrene may be practically determined within fifteen hours. More 
than fifty cases of this kind are now on record in surgical literature, 
and the condition is one well worthy the prompt attention of the sur- 
geon, because only by surgical intervention — i. e. by resection of the 
necrotic mass of intestine — can life possibly be saved. Thus, Elliot 1 
successfully resected 1\ metres of intestine for this purpose. 

Pat-embolism. 
Pat-embolism as a distinct, sometimes fatal, surgical condition 
has received of late so much study as to be now entitled to considera- 
tion by itself. By this term is meant a plugging of small arteries by 

1 Annals of Surgery, Jan., 1895, p. 9. 



SURGICAL PATHOLOGY OF THE BLOOD. 35 

minute drops of fat, which, having been set free somewhere about the 
periphery, are carried into the venous circulation and thence dis- 
tributed to various parts of the system. Inasmuch as the capillaries 
of the lungs are often the first lodging-place, fat-embolism here is 
most often met with, and consequently recognized and studied. But 




Pulmonary capillaries filled with fat in fat-embolism. 



it may obtain in the brain, the choroid, the kidneys, or other parts, 
provided only that there has been sufficient vis a tergo on the part of 
the heart to force the fat-globules through the pulmonary capillaries 
and into the systemic circulation. 

Fat-embolism occurs relatively quite often, and to a slight extent 
in nearly every case of fracture and laceration. So common is it, and 
so closely allied are some of its most prominent symptoms to those of 
shock, that as a matter of fact many cases heretofore considered shock 
are really to be regarded as instances of this condition. Indeed, even 
in a miscellaneous series of 260 dead bodies fat-embolism was found in 
10 per cent. The injuries most likely to be followed by it are simple, 
and particularly compound fractures of bones ; laceration of soft 
parts, especially of adipose tissues ; certain surgical operations ; acute 
infections of bone and periosteum ; rupture of fatty liver ; and certain 
pathological conditions where the phenomena are not so easily 
explained — e. g. icterus gravis, diabetes, etc. 

Drops of fat may be seen floating on fluid or semi-fluid blood after many 
operations and compound injuries, and the possibility of escape of fat; — or, 
more accurately, its suction into the vessels from which this blood has escaped 
— is easily appreciable. But it has also been shown that absorption of fat is 
possible even from serous surfaces, and that fat-embolism may occur when fluid 
fat has been passed into the heart through the thoracic duct, although more 
slowly. Oil-drops are also found in the interior of the tissues, while in a piece 
of lung spread out in water in the visible vessels highly refracting fatty mate- 
rial may be noted. Fatty infarction, particularly in the lower lobes, is some- 



36 SURGICAL PATHOLOGY. 

times plainly visible to the naked eye. Under a low objective, especially 
with osmic-acid staining, the presence of fat is easily and beautifully demon- 
strated. 

The essential danger in case of fat-embolism is of so clogging 
the pulmonary capillaries that oxygenation shall become^ so_ imper- 
fect as to lead to absolute asphyxiation from carbonic-dioxide poi- 
soning. When this fact is understood, the cyanosis, the rapid 
breathing, the over-action of the heart, etc. are easily and correctly 
interpreted. 

Fat-embolism by itself cannot cause inflammation nor infection 
nor sepsis in any sense. It may, however, lead to ecchymoses in con- 
junction with fatty infarcts in the organs most affected. The minute 
hemorrhages are easily explained by bursting of the capillaries in the 
attempt to force blood through them. Fatty emboli, however, take 
the same course as do septic — are carried first to the right side of the 
heart and distributed over the lungs ; are, if the patient live, forced 
through the lungs into the systemic circulation, and are then carried 
to the brain, kidneys, etc. The first symptoms are referable to the 
plugging of the pulmonary capillaries ; the secondary symptoms to 
the systemic disturbance. 

Symptoms. — Pallor of countenance with facial expression of anx- 
iety and distress, followed by cyanosis and contracted pupils, are seen. 
Patients are usually first excited, sometimes more or less disturbed, 
then become somnolent, and, finally, comatose in the fatal cases. The 
respiration-rate increases from normal up to 50 or 60, and breathing 
is sometimes stertorous. Dyspnoea, increasing in intensity until it 
becomes agonizing, sometimes marks these cases. Occasionally foam, 
possibly blood, proceeds from the mouth, as in oedema of the lungs. 
Occasionally, too, haemoptysis occurs. The pulse becomes weak, fre- 
quent and irregular, while toward the close it is fluttering. Tempera- 
ture is not notably disturbed, at least not typically. 

These symptoms set in usually within thirty-six to seventy -two 
hours after the lesion which has caused them. I have, however, 
known death to occur in one or more cases within eighteen hours after 
reception of injury. 

After fat has been forced through the lungs and carried to the 
kidneys it will be eliminated with the urine, and may be found float- 
ing upon it in the shape of oil-like drops. Discovery of this condi- 
tion is positive evidence of fat-embolism. It is to be distinguished 
from shock in that by the time the symptoms of embolic disturbance 
are at their height, all or nearly all symptoms of pure shock should 
have subsided. Furthermore, cyanosis and embarrassment of respi- 
ration are not indicative of shock ; and, finally, the discovery of fat 
in the urine will be corroborative. 

A mild degree of fat-embolism may be noted, if looked for, after almost all 
serious fractures. It will give rise to slight embarrassment of respiration and 
cyanosis and to the elimination of fat by the kidneys. 

Prognosis.— Prognosis is somewhat in proportion to the extent 
of the injury and the proximity of the lesion to the heart and lungs ■ 
also to the possibility of continuous entrance of fat^-t. e from its 



S'UROICAL PATHOLOGY OF THE BLOOD. 37 

continual absorption. Prognosis really depends upon whether the 
heart can be given sufficient vigor and endurance to continue pump- 
ing blood with its burden of fat through the pulmonary circulation. 
A secondary danger may come from the circulation of this fat-ladened 
blood through the capillaries of the brain. Should the source of 
motive power thus become paralyzed along with general enfeeble- 
ment, death may ensue. When well-marked evidences of fat-embolism 
are present, but are followed by recovery, the worst of the trouble is 
usually over within forty-eight hours after it begins. 

Treatment. — Obviously, treatment is mainly directed toward the 
heart that it may stimulate it to carry its load of fat through from 
the venous into the arterial system. If it can do this, the fat is dis- 
posed of by oxidation or is saponified by the alkalies in the blood. 
Physiological rest of the injured part is the first indication, however, 
and if this occur in a patient, say with delirium tremens, powerful 
mechanical restraint may be necessary. The most powerful cardiac 
stimulants are called for — alcohol, digitalis, strychnia. In other 
respects treatment is largely symptomatic. Next to giving the heart 
vigor in this way, inhalations of oxygen give the most promise, 
because of the crying need of the system during this ordeal for this 
life-giving gas. 1 



The Corpuscular Elements op the Blood. 

Within the past few years has eome into a considerable importance 
the so-called third corpuscle or blood-plaque, minutely described by 
Osier and others. It is composed of colorless protoplasm, averaging 
1\ p. (mikrons) in diameter, and is present in proportion of about one 
to twenty of the red blood-corpuscles. While circulating in the blood 
these plaques do not ordinarily cohere, but immediately on their with- 
drawal they form aggregations ; to which fact is due the lack of their 
earlier recognition. They are most numerous in the infant and in the 
aged. Their presence is not yet fully accounted for, and their rela- 
tion to the formation of other corpuscles not yet distinctly determined. 
In acute infectious diseases and in certain chronic wasting forms they 
exceed their normal proportion. During crises of fevers and during 
convalescence from acute and extensive suppuration they are most 
often seen in large numbers. 

The blood-plaques are not the only corpuscles of the blood which 
undergo rapid increase or diminution in number, since this is true 
also of the leucocytes, which during acute inflammations rapidly aug- 
ment in number. Whether this is to furnish more which may escape 
from the blood- vessels and act as phagocytes, or whether destined to 
some other purpose, is not yet settled, though the former is probable. 
Under many of the circumstances connected with phlegmon and 
active corpuscular escape it is found that the spleen and lymph-nodes 
are materially enlarged. Temporary increase in the proportion of 
leucocytes is known as leucocytosis, which is a usual accompaniment 
of suppuration, even though the focus of activity be small. Diminu- 
1 See paper by the writer, N. Y. Med. Jour., Aug. 16, 1884. 



38 SURGICAL PATHOLOGY. 

tion in number of white cells is oligoleucocythsemia, and its sig- 
nificance will be alluded to below. The relation of the leucocytes, 
which contain most of the paraglobulin and peculiar ferment which 
are such important factors in the coagulation of blood, to thrombosis 
is most important ; and it must naturally follow that breaking-down 
of these cells — i. e. release of such materials — will have very much to 
do with coagulation, and that, therefore, thrombosis may be a frequent 
accompaniment of leucocytosis in inflammation. The colorless cor- 
puscles contained in the blood and lymph present several varieties 
more or less distinct from each other, and are classified as follows : 

Lymphocytes. — Small leucocytes with large, round nuclei and a 
relatively small amount of protoplasm, occurring conspicuously in the 
lymph-nodes. They stain readily, especially with aniline dyes, which 
color the nucleus deeply and the protoplasm faintly. These lympho- 
cytes grow until they become large-sized leucocytes, and it is charac- 
teristic that the larger they grow the more easily their protoplasm 
stains and the less so their nucleus. As they attain larger size their 
nuclei sometimes change in shape, and it is not always easy to distin- 
guish a large mononuclear leucocyte from certain fixed connective- 
tissue cells or endothelial cells. 

The eosinophile leucocytes contain in their protoplasm granules 
which do not stain with basic aniline dyes, like fuchsin, methyl vio- 
let, etc., but which readily take up the acid aniline colors, especially 
eosin ; whence their name. In this variety the nucleus is variable in 
shape and form, and is often lobed. 

Another form is represented by cells in which the nucleus is either 
lobed or composed of portions united by delicate filaments, giving the 
impression of a multinuclear cell — in fact, the nuclei often are really 
multiple. Hence this form is known as the polynuclear form. 
These leucocytes also contain a small central body of chromatin and 
polar filaments of achromatin. Their nuclei are deeply stained by 
aniline dyes, while their protoplasm remains for the most part unaf- 
fected. This latter is granular, and can only be stained by a mixture 
of acid and basic dyes, so that these polynuclear forms are often 
spoken of as neutrophil?. This form comprises about three- fourths of 
the total number of leucocytes in the blood. The term formerly used, 
myelocyte— i. c. a cell supposed to be found in the bone-marrow and 
distinct from the other leucocytes— has been nearly abandoned. Ehr- 
lich, who 1ms been the leader in this study of blood-cells, has shown 
that the eosinophile cells form in the blood at the expense of smaller 
ones which have been produced in various organs. Consequently an 
undue proportion of eosinophile cells indicates pathological activity 
of bone-marrow and betokens one form of leucocythsemia 

The entire modern study of leucocytes of the blood is based upon 
their reaction to certain staining agents, for the most part the aniline 
dyes. According to these reactions in connection with peculiarities 
of size shape, etc., we speak, then, to-day of the following varieties 
ot white corpuscles : 

1. Lymphocytes, derived from lymphoid tissues of the body • in 
number from 20 to 30 per cent, in the leucocytes of the blood. Their 



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Fig.V. 








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DRAWN fli J*7 CM.;; 



PLATE I. 

BLOOD. 

(Prepared by Dr. I. P. Lyon.) 

Fig. I. TYPES OF LEUCOCYTES. 

a. Polymorphonuclear Neutrophile. b. Polymorphonuclear Eosinophile. 
c. Myelocyte (Neutrophilic), d. Eosinophilic Myelocyte, e. Large Lymphocyte 
(large Mononuclear.) /. Small Lymphocyte (small Mononuclear). 

Fig. II. NORMAL BLOOD. 
Field contains one neutrophile. Reds are normal. 

Fig. III. ANAEMIA, POST-OPERATIVE (secondary). 

The reds are fewer than normal, and are deficient in haemoglobin and 
somewhat irregular in form. One normoblast is seen in the field, and two 
neutrophiles and one small lymphocyte, showing a marked post-hasmorrhagie 
anasmia, with leucoeytosis. 

Fig. IV. LEUCOCYTOSIS, INFLAMMATORY. 

The reds are normal. A marked leucoeytosis is shown, with five neutro- 
philes and one small lymphocyte. This illustration may also serve the purpose 
of showing the leucoeytosis of malignant tumor, except that in this disease (ma- 
lignant) the reds show a well-marked secondary ansemia. 

Fig. V. TRICHINOSIS. 
A marked leucoeytosis is shown, consisting of an eosinophilia. 

Fig. VI. LYMPHATIC LEUKEMIA. 

Slight anaemia. A large relative and absolute increase of the lymphocytes 
(chiefly the small lymphocytes) is shown. 

Fig. VII. SPLENO-MYELOGENOUS LEUKEMIA. 

The reds show a secondary anaemia. Two normoblasts are shown. The 
leucoeytosis is massive. Twenty leucocytes are shown, consisting of nine neu- 
trophiles, seven myelocytes, two small lymphocytes, one eosinophile (polymor- 
phonuclear) and one eosinophilic myelocyte. Note the polymorphous condition 
of the leucocytes, i. e., their variations from the typical in size and form. 

Fig. VIII. VARIETIES OF RED CORPUSCLES. 

a. Normal Red Corpuscle (normocyte), b, c. Ansemie Red Corpuscles. 
d-g. Poikiloeytes. h. Microeyte. i. Megalocyte. j-n. Nucleated Red Corpuscles. 
j,k. Normoblasts. /. Mieroblast. m, n. Megaloblasts . 



SURGICAL PATHOLOGY OF THE BLOOD. 39 

nucleus is large, and their non-granular protoplasm appears only as a 
narrow rim. 

2. Large mononuclear forms, with large, oval, feebly-staining 
nuclei and a fair quantity of non-granular protoplasm ; 2 to 3 per 
cent. 

3. So-called polynuclear leucocytes, those with polymorphous nuclei. 
These represent two-thirds of the whole number of leucocytes. They 
are smaller than No. 2, and have irregular nuclei. Their protoplasm 
contains numerous neutrophilic granules, and they are often called 
polynuclear neutrophiles. 

4. Transitional forms, similar to No. 2, with irregular nuclei, in 
transitional stage from mono- to polynuclear form, constituting about 
3 per cent, of the entire number. 

5. Eosinophile cells, same size as No. 3 ; nuclei variable, protoplasm 
largely made up of refractive eosinophile granules. They constitute 
from 2 to 4 per cent, of the total of leucocytes, and originate in bone- 
marrow. Nos. 2, 3, and 4 are regarded as formed in both spleen and 
bone-marrow. 

These proportions are fairly constant in a state of health ; in the 
presence of certain diseases they vary widely. Hence the value of 
proper estimation and recognition of their relative proportion. It is 
also generally accepted that in certain diseases cells not met with in 
health may be found in the blood. These have not yet been suffi- 
ciently studied, but their recognition is a matter of growing import- 
ance. Their various appearances are indicated in Plate I. 

Leucocytosis as an Element in Diagnosis. — Leucocytosis dif- 
fers from leuccemia in that while both refer to the increase of the actual 
number of white corpuscles in a given volume of blood, and while in 
both instances these belong to the classes found normally present, in 
the former instance the condition is a temporary and evanescent one, 
while in the latter it is a permanent one and constitutes a marked fea- 
ture of the disease. It is perhaps incorrect to say that in leucaemia 
only the normal types of cells are present. All of the normals are 
present, but there are also present those which are not found under 
normal conditions. In leucocytosis the increase is mainly in the poly- 
nuclear cells. 

The normal standard implies that in a cubic millimetre of blood there should 
be present about 7,500 leucocytes to from 5,000,000 to 5,500,000 red blood-cells ; 
but the relative proportion of whites varies even from hour to hour within cer- 
tain limits, and a relative leucocytosis is normal during digestion of a hearty 
meal, during pregnancy, and in newly-born children. But, as an index of ab- 
normal conditions, one may say in a general way that leucocytosis as a diseased 
condition is nearly always associated with the inflammatory process, with cer- 
tain malignant tumors, and in other rare conditions which may be mentioned 
below. Any variation of more than 1,500 above or below the above standard 
of 7,500 should be considered abnormal. 

In malignant disease, especially in the soft and rapidly-growing 
tumors, and particularly in sarcoma of bone, there is marked leucocy- 
tosis, by which in doubtful cases a distinction may be made before 
operation between malignant conditions and tuberculosis, chronic 
arthritis, etc. It is furthermore stated that in malignant disease, 
even when no leucocytosis is present, a differential count of stained 



40 SVEG1GAL PATHOLOGY. 

specimens will show marked increase in the percentage of polynuclear 
cells. In all forms of suppuration, deep or superficial, circumscribed 
or diffuse, and in all types of septic invasion and infection, leucocy- 
tosis is present. Cabot has shown how the test may be applied in 
eases of deep wounds, compound fractures, etc., where one is dis- 
turbed by rise of temperature, etc. and hesitates whether or not to 
re-dress the wound. If there be no leucocytosis present, there need 
be no fear of retained or accumulating pus. Furthermore, in such 
a case — for instance, as one of uncertain diagnosis between typhoid 
and purulent meningitis — an increase of leucocytes will point surely 
to the latter ; and diagnosis has been corroborated by the discovery 
of middle-ear disease, from which the meningeal complications pro- 
ceeded. 

It will be seen, then, that the relative and numerical estimate 
of the richness of the blood in its white corpuscular elements may 
be of the greatest service to the surgeon by furnishing indications 
of importance for the subsequent management of the case or for 
diagnosis. 

Red Corpuscles. — With care in examination certain differences 
can be detected in the behavior and size of the red corpuscles, which 
may also furnish important information. This brings up mainly in 
this connection the question of the anaemias, which are relative and 
jjotiitive. After an acute loss of blood, as after operation or accident, 
there is, of course, a deficiency in the amount of blood in the system, 
which, however, does not materially influence the proportion of reds 
to whites nor the number of reds present in a given volume. Oligocy- 
themia is a term applied to a deficiency of red corpuscles, or to a con- 
dition by which their relative proportion is recognizably lowered. If 
we accept from five to five and a half million of red cells in a cubic 
millimetre as the normal standard, it will be seen that we may have 
various degrees of oligocythsemia, which, however, is rarely reduced 
below a proportion of two million. Poikilocytosis is a term applied 
to that condition in which the red corpuscles are irregular in shape 
and in size, these irregularities varying from the slightest crena- 
tion of their borders up to a very marked alteration in all their 
proportions. 

It is possible, then, without long special training, to estimate both the 

Physical Properties of the Leucocytes. 

Phagocytosis. — All leucocytes have the power of shifting their 
location. The lymphocytes, so called, being the youngest of the 
white corpuscles, show it less than do even the older forms. Also 
the eosinophile cells are less able to manifest the peculiar activities 
of the other forms. It is particularly the mono- and polynuclear 
corpuscles which are endowed with most pronounced activity. These 
have the power, like the anifebie among the lowest forms of life, to 
not only spread themselves around inert bodies, like granules of car- 
mine or other particles used for experiment, or the particles of coal- 
dust found in certain conditions in the human body, but they have 
also the power to englobe many living organisms, for the most part 
vegetable (bacteria). Under the microscope it is possible to see liv- 



SURGICAL PATHOLOGY OF THE BLOOD. 



41 




ing bacilli performing active movements although enclosed in the 
nutritive vacuoles of the leucocytes in some of the lower animals. 
This amahoid power possessed by 
these cells of thus attacking and 
disposing of foreign bodies or ir- 
ritants has been demonstrated and 
proven, especially by Metchnikoif, 
and has been called by him phago- 
cytosis. His views were for a long 
time disputed, and are perhaps not 
yet absolutely and generally ac-ftj 
cepted. Nevertheless, they fulfil 
even- demand made upon them for 
explanation, and are susceptible of 
such demonstration under the mi- 
croscope that we now have practi- 
cally a new and apparently a cor- 
rect theory of the inflammatory 
process. (See next chapter.) Any 
cell which has this property is 
known as a phagocyte. It is 
shared by certain of the leuco- 
cytes with certain other cells to 
be spoken of later (wandering tis- 
sue-cells). Cells which possess 
this power do not attract all mi- 
crobes indiscriminately, and it is 
often the case that the leucocytes of an animal peculiarly susceptible 
to a certain kind of bacteria do not attract them at all, even 
though they be directly in contact. It is plausible that an expla- 
nation of the peculiar susceptibility of certain animals to certain 
diseases is furnished by this fact. (See Fig. 4.) 

On the other hand, leucocytes may and do englobe virulent mi- 
crobes. In man the mononuclear forms do not take up either the 
streptococcus of erysipelas or the gonococcus ; whereas these two 
organisms are readily attracted by the polynuclear neutrophile cells. 
The bacillus of leprosy, on the other hand, is never attacked by the 
polynuclear forms, but is speedily devoured by the mononuclear cells. 
This shows that the various leucocytes may exercise a marked selec- 
tive ability. This inclusion of minute bodies within amoeboid cells 
seems to be an evidence of a peculiar tactile sensibility upon the part 
of the latter. In fact, this is clearly established, and seems to be 
inseparable from the peculiar attraction between leucocyte and bac- 
terium to which the name chemotaxis has been given, and which is 
described in the ensuing chapter. If the included organism be, as is 
usually the case, killed, it is disposed of by a true process of intracel- 
lular digestion in a neutral or alkaline protoplasmic medium, and its 
inert portions are again extruded. On the other hand, if the leuco- 
cyte be poisoned or die in this phagocytic attempt, it presents usually 
as a so-called pus-ce\\ or corpuscle, and the solid part of pus is made 



Active phagocytosis. Endothelial cells en- 
closing the bacilli of swine septicaemia, 
from an hepatic vein of a pigeon : a, endo- 
thelial cells ; b, leucocytes (Metchnikoff). 



42 SURGICAL PATHOLOGY. 

up in large measure of cells which have perished in this way. (See 
next chapter.) 

To regard phagocytosis as an affair mostly of certain tissue-cells arid 
invading bacteria would be altogether too narrow a view to take of it. 
It is really a process of the greatest importance and of constant per- 
formance in our systems. By virtue of it disintegrated muscle-fibres 
and other tissue-cells are disposed of, sloughs are separated, certain 
absorbable foreign bodies (catgut, etc.) taken away — i. e. absorbed — 
cellular tissue reduced in numerical strength (progressive atrophy) ; 
and a great variety of changes, either normal, as those pertaining to 
health and advancing years, or abnormal, like those incident to many 
diseases, are actually the product of this kind of phagocytic activity. 
The protective power, then, which the phagocytes exert as against 
bacteria is only one part of their normal functions, by virtue of 
which they become, in effect, perhaps the most important cells within 
our bodies. Their powers are limited, however, as will be seen when 
describing pus, for the so-called pus-corpuscle is nothing but a phago- 
cyte which has perished in its self-assumed task. It is known also 
that in certain instances phagocytes, which are incapable of defence 
as against the mature bacterial organism, are nevertheless capable of 
englobing its spores and preventing their development. This is true, 
for instance, in case of anthrax in animals ordinarily immune, as, for 
instance, the frog and fowl. If, however, in these very animals the 
vitality of the phagocytes be affected — as by cooling in fowls or heat- 
ing in frogs — phagocytosis is so far interfered with that the spores 
germinate within the enfeebled leucocytes and the entire organism is 
infected. (Vide also Plate II. Fig. 1," illustrating diapedesis.) 

HEMOGLOBIN. 

The principal interest of the red blood-corpuscles for the surgeon, 
aside from their relative number and shape, inheres in their relation 
to liEemoglobin, and haemoglobin is of particular interest here because 
much can be learned by estimating the proportion in which it be 
present. That the amount contained in the blood varies within wide 
limits under different conditions has long been known. The ideal 
normal standard is present in but a small proportion of cases, even in 
strong young men in the third decade of life. The average is con- 
siderably lower and can scarcely be placed above 90 per cent. Fe- 
males show a smaller amount ' than males — 3 or 4 per cent, lcs* 
After haemoglobin loss, as after surgical operations, much can be 
gained in the matter of prognosis by estimating the speed of it* re- 
generation. With regard to how much actual hemoglobin loss a 
patient can bear, it seems to be more important to determine how 
much still remains in the body. The minimum is apparentlv 90 per 
cent. In three cases dying of collapse after operation Mikulicz found 
only lo per cent, remaining. The rapidity of regeneration is a fairly 
accurate indication of improvement in every other respect. Regener- 
ation is interfered with by constitutional syphilis, and, on the other 
hand, is often apparently favored in cases of tuberculosis. In malig- 
nant tumors the average of haemoglobin is reduced to about 60 per 



SURGICAL PATHOLOGY OF THE BLOOD. 43 

cent., and in these cases also complete regeneration is materially re- 
tarded. Incomplete removal or recurrence of cancer prevents typical 
regeneration or restoration, while after successful or radical removal 
complete restoration to the previous standard, often with positive 
gain, is obtained. Thus, a woman who had gained thirty pounds 
after resection of a cancerous pylorus showed after three months 
haemoglobin repair to the amount of 65 per cent. A prognostic sig- 
nificance often attaches to the accurate estimation of nsemoglobin at 
intervals after removal of malignant tumors. 1 

1 See Park's Lectures on Surgical Pathology, p. 13. 



CHAPTEE III. 

INFLAMMATION. 
By Eoswbll Pakk, M. D. 



Inflammation is an expression of the effort made by a given organism to rid itself 
of or render inert noxious irritants arising from within or introduced from without 
(Sutton, modified). 

After having duly considered hyperemia as a phenomenon having 
an identity and termination of its own, we are prepared to study the 
more complex processes implied under the term inflammation, the 
first of which is the hyperemia already considered. The characteris- 
tic of the truly inflammatory process is that it does not stop with 
mere congestion nor with any of its above-mentioned terminations, 
but goes on to something more complex, now to be described. It 
must be understood, therefore, in this consideration that hypersemia 
here is the first act of the vessels, resulting from peculiar stimuli 
which must shortly be considered. Even the hypersemia seems to be 
now more distinct than under other circumstances, and along with 
the dilatation of vessels and the stagnation of blood-current the capil- 
lary vessels now seem crowded with blood-corpuscles to an abnormal 
degree, the rapidity of their motion is checked, and there is accumu- 
lation of blood-cells along the walls of the small veins, to which they 
seem to adhere as if by some new cohesive property. The result is 
that before long the vessel-wall appears to have received a new coat- 
ing of white corpuscles, this being more marked in the veins than in 
the arterioles, while in the latter the red are more numerously min- 
gled with the white than in the veins, in which the distinction be- 
tween the two classes of cells is better maintained. 

Next comes the phenomenon whose clear recognition and descrip- 
tion is inseparably connected with Cohnheim's name. This is known 
under dhTerent names as migration or diapedesis of the leucocytes. 
The programme is about as follows : A little protrusion of the vascular 
wall, a marked alteration in the shape of a leucocyte, which yet ad- 
heres to this point of its lumen, and then the curious fact so often seen 
under the microscope — the gradual passage of this cell throuo-h the 
vascular wall, from its inner to its outer side, by what is generally 
known as its amceboid movement. This migration of the leucocyte is 
not confined to its mere escape from the restriction of the vessel-lumen 
but goes on to an indeterminate extent after it has detached itself from 
the outer surface of the vessel. This seems to occur by virtue of the 
same amoeboid characteristic which it exhibited in passing through 
between the cells of the vessel itself. If this occur at one point, it 
occurs at innumerable points, in consequence of which a large number 

44 



PLATE II. 






N 




T3K 






5 ^S^**r^«^*^ 



Small Vein showing Diapedesus of Leucocytes; ., Leucocyte escaping between 

Endothelial Cells; i,c, Leucocytes escaped; / Leucocytes migrating 

toward centre of attraction. (Engelmann.) 



FIG. 2. 



$ ' ■ & 



m ». 



V*"-' 




Septic Thrombosis of Pulmonary Capillaries, after Puerperal Septicaemia, 
Sh.o wing, rapidly increasing colonies of Streptococci. (Klebs.) 



INFLA MM A TION. 45 

of leucocytes escape into the tissues of the part involved. This diape- 
desis occurs most markedly from the smaller veins, to a less extent 
from the capillaries. The cells which escape from the latter are usually 
accompanied by more or less red cells, the consequence being that the 
exudate which necessarily occurs at the same time is more or less 
tinged with the coloring matter of the blood, and is known as a hem- 
orrhagic exudate. (See Plate II., Fig. 1.) 

The above phenomenon, described in so few words, is in its minutiae 
a really complex one, depending on a variety of causes not easily ap- 
preciated ; but it is at least positive and well known, because it can be 
observed at will in the mesentery or web or tongue of certain animals 
which can be confined upon the stage of the microscope. The phe- 
nomena of inflammation, therefore, comprise, first, hyperemia, and then 
escape from the blood-vessels of the corpuscular and fluid elements of 
the blood. The former may be due, as already seen, to various irri- 
tations of a non-specific character ; while, as we shall learn, the latter 
practically never take place save when the irritation has been, as 
pathologists like to say, specific or infectious. 

The phenomena of true inflammation comprise practically the roles 
played by the three elements which conspire to produce those changes 
— namely, the tissues, the blood, and the specific irritants which are the 
primary causes of the entire lesion. Each of these must be considered 
separately. 

All observers agree that in actively inflamed tissues the number of 
cells is very greatly increased. A certain increase may be accounted 
for by that which has been already described — namely, the escape into 
the tissues of the wandering cells from the blood-vessels. But neither 
this alone nor the products of their rapid proliferation are sufficient to 
account for all the cells found in the truly inflammatory condition. 
It is now well established that in connective tissue there are two 
varieties of cells — the fixed and the wandering — the former concealed 
in the trabecular of the intercellular substance, while the latter are 
small, ordinarily round in shape, much resembling the white corpus- 
cles, possessed of amoeboid characteristics, and having the power of 
changing position. These are known as the wandering cells, which 
meander through the lymph-spaces of the tissues or back and forth 
into and out of the blood-vascular system, their migration being regu- 
lated by causes not yet known to us. Under natural conditions their 
number is relatively small. Once given a true inflammatory disturb- 
ance, and they are reproduced with amazing rapidity ; and their num- 
bers, added to those produced by diapedesis of leucocytes, with the 
combined proliferative activity of both forms, serve to account for the 
new cells whose presence characterizes phlegmonous and other similar 
disturbances. That these wandering connective-tissue cells have much 
to do with these changes is shown by the recently pointed-out but 
unmistakable evidences of excessive activity known as karyokinesis 
(/. e. nuclear activity). 

Karyokinesis is common not only in inflammatory disturbances, but 
in new growths of rapid formation, especially sarcomata, which are 
formed from mesoblastic cells, the same which have to do with con- 
nective tissue. Endothelial cells also undergo the same changes. 



46 SURGICAL PATHOLOGY. 

The peculiar characteristics of the leucocytes have been already 
described at considerable length in the preceding chapter. It must 
suffice, then, here to say that during the inflammatory attack the leu- 
cocytes are increased in number — ■/. e. there is a temporary leucocyto- 
sis which is the usual accompaniment of suppuration. (According to 
Cabot, this is regularly present in purulent, but not in catarrhal forms 
of appendicitis.) The recognition of this fact may be of great value 
in diagnosis. For instance, leucocytosis is rarely present in tubercular 
disease unless suppuration complicate the case. It is met with in 
suppurative osteomyelitis and in all cases of pocketing of pus. More- 
over, when leucocytosis is present coagulability of the blood is 
increased. Of the various leucocytes, it is the mononuclear and poly- 
nuclear forms which are endowed with the most pronounced activity 
and which play the principal r6le among the blood-cells or phagocytes. 
That phagocytosis plays a most important part in the inflammatory 
process is a matter to be emphasized in more than one way and in more 
than one place. The account of the process already given must suffice 
for descriptive purposes ; the importance of the act, however, must 
be made most prominent in considering inflammation and suppuration. 
That the phagocytic properties of these cells are limited will be 
remembered when we recall that in certain instances phagocytes, 
which are incapable of defence as against the mature bacterial organ- 
ism, are yet capable of englobing the spores and preventing their 
development. Nevertheless, the activities of even the most lively 
phagocytes are capable of being influenced and repressed by extremes 
of heat and cold to which patients may be exposed, either locally or 
generally. 

Chemotaxis. 

Having considered briefly the cells which take prominent part in 
the inflammatory process, and the escape along with them of the fluid 
portions of the blood, whether these coagulate or not, it is necessary 
before speaking of specific factors to discuss for a moment that which 
induces the above cells to act in this way. That there is a peculiar, 
even a mysterious, attraction which brings specific irritant and phago- 
cyte together has been for some time recognized, but it remained for 
Pfeffer to study it carefully and to give it the name by which it now 
passes — i. e. chemotaxis— while others have widened our knowledge of it. 

Chemotaxis is a term implying a peculiar property of attraction 
and repulsion between, cells, both animal and vegetable. It mainly per- 
tains to vegetable cells alone, and has been offered as the explanation 
of the sporulation of ferns, for example ; but as it interests us most 
in this place, it is manifested between the animal cells of the human 
body and the bacteria, which are vegetable cells. As the result the 
former—?', e. the phagocytes— having power of migration, are drawn 
toward the latter. To be more accurate, this mutual or peculiar 
attraction is known as positive chemotaxis, it being also known that 
exactly the reverse obtains under certain circumstances, and that 
mobile cells will move away as rapidly as possible from certain 
organisms or substances for which they seem to have a repugnance, 
this being known as negative chemotaxis. 



INFLAMMATION. 47 

Specific Irritants. 

These are essentially living organisms, grouped for the most part 
among the bacteria, fungi, and the protozoa, the first named being by 
far the most frequent. Before a lesion can assume the type of inflam- 
mation as here understood some one or more of these organisms must 
have secured an entrance into the tissues, the circumstances determin- 
ing such invasion being considered a little farther on. It is these 
living organisms which, having once invaded the tissues, determine 
that most active congregation and proliferation of certain cells which 
we have just described under the head of Phagocytosis. When once 
the irritants are present, there begins that very active conflict which 
Yirchow has so graphically alluded to as the battle of the cells. Now 
the mysterious chemotactic properties of the component substances 
manifest themselves, and now phagocyte is drawn toward bacterium, 
or the reverse, while the tiny war goes on with sometimes varying 
results, it being a question which can prove victor in the conquest. 
This is no fiction of the imagination, but is again a contest which may 
be seen under the microscope in certain of the lower animals, while 
its results may be seen in the examination of pus from any human 
source. In another place I have likened also this conflict to that in 
which certain of the enemy resort to poisoned weapons, because 
modern biological chemistry has now shown very evidently that it is 
a part of the life-history of many of these micro-organisms to produce, 
probably as excretory products, albuminoid or other substances having 
sometimes extremely toxic properties. And so it comes about that in 
many of the surgical infections, while the local destruction is produced 
by the actual death of tissues which have been invaded by micro- 
organisms, the general or systemic symptoms, ordinarily spoken of as 
the toxic symptoms, are literally due to poisons generated in the 
infected area, dispersed throughout the system, and often proving 
fatal. 

The local effect of these specific irritants when they are not promptly 
attacked, devoured, and removed by phagocytes is pus, which means 
cellular death, or gangrene, which is death of masses of cells which 
have not had time to separate from each other. Pus, then, is the 
ordinary consequence of the contest above alluded to, and each pus-cell 
represents the dead body of a phagocyte which has perished in the at- 
tempt to protect the parent organism from harm. That it has died 
valiantly can almost invariably be determined, because within its dead 
body may be seen the body of one or more of the minute invaders 
which it has attacked. This, then, is the light in which inflammation 
and infection should be viewed. 

In other words, we may have escape of fluid portions of the blood, 
which may or may not coagulate ; we may even have some escape of 
corpuscular elements with some activity in the extravascular cells, 
which shall lead to temporary or even permanent enlargement of a 
part; all of which may be provoked by injury or by the presence of 
certain chemical irritants within the blood or tissues ; for example, 
alcohol, uric acid, etc. But the factors which provoke the greatest 
activity on the part of intra- and extravascular cells, and which deter- 



48 SURGICAL PATHOLOGY. 

mine the richness in albumen of fluid exudates, or their prompt coagu- 
lation so soon as blood-serum has escaped from the vessels, and which 
particularly determine the furious rush of phagocytes and that kind 
of intercellular conflict which leads many of the contestants on both 
sides to death, are living organisms which are introduced from 
without, whose presence at the point of inflammation is abnormal and 
injurious, which are offending substances in every respect, while the 
whole phenomenon of inflammation is an expression of an effort to 
rid the system thereof. Taking this view of the subject, there is a 
most important distinction between hypersemia andits consequences, 
which is absolutely a non-infectious condition, and inflammation and 
its consequences, which is always an infection and is always followed 
by more or less death of cells, the same being often extruded m a 
semifluid mass known as pus. 
Next must be studied the — 

Circumstances which Favor Infection. 

1. The Virulence of the Infecting Organisms and the Amount 
Introduced. — There is the widest difference between various forms 
of micro-organisms in the matter of virulence ; and it is true that 
there are very great differences between the same species under dif- 
ferent circumstances, these differences depending on conditions as yet 
absolutely unknown. With certain organisms it is enough to infect 
an animal with one alone in order to bring about a fatal result, this 
meaning that the organism itself is extremely virulent and the animal 
extremely susceptible. 

In a guinea-pig, for instance, a single virulent anthrax bacillus will produce 
death, whereas in a more resistant animal many are required, and in yet others 
there is absolute immunity against the disease. Man is much more susceptible 
to the pyogenic organisms than most of the lower animals, which is one reason 
why wrong deductions have been drawn from many experiments, and why 
veterinary surgeons, who are so careless of all antiseptic precautions, yet, as a 
rule, have good results in work which, done after the same fashion on the 
human being, would be inevitably fatal. It is one reason also why one may 
draw false inferences from experimental work done, for instance, upon dogs, 
which survive many an operation which can scarcely be successfully repeated 
upon a human being. The influences which affect the vitality and virulence 
of micro-organisms are most numerous and widespread. Temperature, sunlight, 
moisture or dryness, association with other bacteria, source, are but a few of the 
conditions known to be more or less operative. Inoculation of a small number 
of certain bacteria may be harmless : up to a certain number it may produce 
only a local disturbance, like abscess, while a still larger dosage may produce 
fatal results. This is not the case with all, however, but only with some organ- 
isms. Bacteria which have been repeatedly passed through the animal body 
become more virulent than those cultivated for many generations in test-tubes 
in the laboratory. This variable virulence is especially characteristic of the 
colon bacillus, the anthrax bacillus, and the micrococcus of erysipelas. Nor 
does it always follow that the most virulent organism is necessarily cultivated 
from the most toxic or serious manifestation of its activity. 

2. Association. — Bacteria are seldom found in pure cultures 
under natural conditions. By mutual association remarkable changes 
are produced, sometimes in the direction of enhanced virulence some- 
times in the direction of attenuation of effect. Certain organisms 
extremely dangerous alone, lose their power when combined with 



INFLAMMATION. 49 

others, while still others have their virulence increased to a rapidly 
fatal degree. In fact, these effects are so strange and so contradictory 
that no law governing them has yet been formulated, it being neces- 
sary to establish each case by experimental investigation. The viru- 
lence of the anthrax bacillus under ordinary circumstances is well 
known, as is also that of the streptococcus of erysipelas in man. Yet 
when these two organisms are introduced simultaneously the mixture 
is apparently wellnigh harmless. On the other hand, the simulta- 
neous inoculation of certain other species greatly increases the danger 
from either alone. The diplococcus pneumoniae when combined with 
the anthrax bacillus seems to have a greatly augmented power. 

3. Hereditary Influences. — The fact that immunity against cer- 
tain infections and susceptibility to other conditions are transmitted 
from parent to offspring is one which admits of no dispute. The 
explanation, however, is almost as remote from us to-day as it ever 
was. But the recognition of the fact is of the greatest importance to 
all practising surgeons. That bacteria frequently enter through wounds 
and bruises is self-evident, but we all know that such wounds are more 
likely to suppurate in some than in others, and the causes of infection 
in some are, to a certain extent, connected with hereditary habit of 
tissues. The same causes influence not merely liability to infection, 
but its severity and character. There are undoubtedly also local as 
well as general variations, and it is very certain that among these the 
results of bruising or contusion are by far the most prominent. There 
is also undoubted experimental evidence that under certain circum- 
stances bacteria produce only local lesions, whereas under others they 
produce general and even fatal infection. 

4. Local predisposition is a factor of almost equal importance. 
Once given a distinct infection, and hyperaemia is sometimes a con- 
tributing cause of inflammation. Per contra, anaemia of tissues seems 
to be again a favoring condition. In parts involved in chronic con- 
gestion the blood flows more slowly, while the vessels are dilated and 
apparently susceptibility is increased. Infection here produces a type 
of disease ordinarily spoken of as hypostatic inflammation. General 
anaemia, again, is a predisposing cause, while toxaemias, including 
diabetes, etc., are still more so. The liability of diabetic patients 
to suppurative and even gangrenous infections is proverbial. The 
presence of foreign bodies has much to do also, and, infection once 
having occurred along with its introduction, the presence of a for- 
eign body will nearly always excite suppuration ; otherwise, it will 
ordinarily remain inert. The withdrawal of trophic nerve-influences 
also apparently permits infection, as is instanced by the ease with 
which bed-sores form in paralytic patients. Obstruction to the cir- 
culation or to escape of secretions more easily permits infection : for 
example, in the appendix, in the kidney, in the gall-bladder, the sali- 
vary glands, etc. Furthermore, one may formulate a quite comprehen- 
sive statement and say that all such lesions as solutions of continuity, 
hemorrhages, degenerations, vascular stasis produced by strangula- 
tion, etc., and all perforations, increase more or less the liability to 
infection. 

5. Pre-existing Disease. — Here are reckoned — first, previous and 



50 ' • SURGICAL PATHOLOGY. 

long-existent toxaemias— e. g. syphilis, diabetes, scurvy, etc. Other 
conditions, like lithsemia, cholsemia, acetonemia, and the various con- 
ditions represented by oxaluria or in which acetone, peptone, and ex- 
cess of uric acid are found in the urine, come also under this head. 
One need never be surprised to find suppuration occurring in those 
cases in spite of due observance of all ordinary precautions, since by 
their existence immunity is destroyed and vulnerability increased. 
(Vide also chapter on Auto-infections.) 

Recent toxcemias also have important bearing in this same respect. 
For instance, after typhoid fever and other acute wasting disease, in- 
cluding the exanthemata, surgical operations are sometimes followed 
by failure, and should always be postponed until complete recovery, 
except in cases of emergency. The condition to be hereafter described 
as enterosepsis, and which in time past has been spoken of under many 
different names, as fecal anaemia, stercorsemia, etc., is one which posi- 
tively makes dangerous the performance of all operations, and which 
certainly predisposes to septic disturbances of all kinds. The post- 
puerperal state is also one in which operations are to be avoided if 
possible. 

Certain -anatomical changes peculiar to the various ages also belong 
in this category. Old age with its accompanying arterial sclerosis, 
its cardiac debility, and other well-known tissue-alterations, favors 
sluggishness of wound-repair and leads not infrequently to sloughing 
or to bed-sores. Amyloid changes betoken impaired vitality. Chil- 
dren are much more liable to acute osteomyelitis than adults. Nurs- 
ing infants are apparently exempt from many of the infectious 
diseases, but possess relatively small power of vital resistance to 
surgical operations. General ansemia and impaired nutrition of 
the body predispose to most infections, acute starvation notori- 
ously so. 

6. Personal Habits and Environment. — Diet has much to do 
with tissue-resistance. Rats fed on bread are more susceptible to 
anthrax than those fed on meat. Hunger makes pigeons highly sus- 
ceptible to the same disease, and artificial immunity induced in various 
animals is quickly destroyed by starvation. Prolonged thirst seems 
to have the same result. Prolonged fatigue notoriously reduces im- 
munity, as already mentioned. The various drugs which destroy red 
corpuscles impair immunity, and even by injection of water into the 
circulation the bactericidal power of the blood is reduced. White 
mice .fed with phloridzin, which produces artificial diabetes, become 
highly susceptible to glanders, from which they are ordinarily exempt. 
In this connection may also be mentioned the various toxaemias alluded 
to under the previous heading, which may proceed from the intestine, 
from the genito-urinary tract, and probably also from other sources. 
Climate has more or less to do, as also extremes of weather, with 
power to resist infection or to survive serious operations. Dark habi- 
tations, poorly ventilated, constitute surroundings which notoriously 
predispose to infection of all kinds. Rabbits inoculated with tuber- 
culosis and confined within a dark cell, badly ventilated, become rap- 
idly diseased, while others similarly inoculated, but allowed to roam 
at large, present but slight evidences of the affection. Certain occu- 



INFL A 31 MA TION. 5 1 

pations predispose to certain diseases. This is pre-eminently the 
case, for example, with workers in mother-of-pearl, who are exceed- 
ingly liable to a particular form of osteomyelitis ; and with those who 
make phosphorus matches, who are prone to suffer from a peculiar 
necrosis of the lower jaw : that prolonged suppuration may produce such 
changes in the blood and tissues that vital processes of repair, cell- 
resistance, and chemotaxis may be so far interfered with as to facili- 
tate subsequent infection, is a matter upon which I have elsewhere in- 
sisted. 

Finally, the influence of local injury to tissues, particularly of con- 
tusions which cause tissues to lose their vitality, is strenuously insisted 
upon by all, and is spoken of repeatedly in other places in this 
work. Many tissues will succumb to inoculation after bruising, liga- 
ture en masse, etc. which before such injury are not in the le.ast dis- 
turbed. 

7. Fcetal Infection. — It is only in a very limited class of cases 
that infection can be transmitted from mother to fcetus, but there are 
instances of this kind in which the surgeon is deeply concerned. As 
Welch has stated, syphilis is the only infection capable of direct 
transmission through the ovum or spermatozoon ; but intra-uterine 
infection may occur in many ways, and many diseases may be thus 
transmitted. The placenta is usually regarded as a perfect filter ; 
nevertheless, it is occasionally passable by micro-organisms. These 
may be caused by pre-existing lesions in the placenta or by the viru- 
lence and activity of bacteria. It is known that in animals the bacilli 
of chicken cholera (inoculated into the mammalia), of symptomatic 
anthrax, and the pyogenic cocci frequently traverse this barrier. In 
mankind infection in utero has been observed in small-pox, measles, 
scarlatina, relapsing fever, syphilis, tuberculosis, croupous pneumonia, 
typhoid fever, anthrax, and surgical sepsis. 

Sources of Infection. 

That the effects of bacterial invasion may be anticipated and 
guarded against most effectually it is necessary that the practitioner 
be thoroughly familiar with the sources from which they come, and 
the localities in and about the body which they most commonly inhabit 
or where they are met with in largest numbers. 

Skin and Mucous Membranes. — Of all possible sources of infection, 
the skin itself is probably the most fertile. It is exposed to contam- 
ination by air and by everything which may come in contact with the 
body, and there is perhaps no organism ever met with in disease which 
may not be found upon its surface or within its recesses. In fact, 
these recesses, such as the crevices beneath the nails, the spaces between 
the toes, and the various pockets like the tonsils, the axillae, etc., are 
those most commonly inhabited by micro-organisms. 

Bacteria may penetrate the skin by means of three different routes — namely, 
the sweat-glands, the hair-follicles, and the sebaceous glands by means of 
their regular openings. The hairy appendages of the skin are even greater 
sources of danger than the skin itself, since a direct path of infection into the 
depths of the skin is afforded by their follicles. Experimentally it has been 



52 SURGICAL PATHOLOGY. 

shown that when bacteria are rubbed into the skin where there are no follicles, 
there is absolute freedom from infection, whereas the reverse is equally true, and 
it is clinically generally recognized that furuncles and carbuncles form almost 
exclusively in those parts provided with hair and sebaceous glands. 

The mucous membranes are in constant contact with micro-organisms, and 
furnish conditions in many respects favorable for their rapid development. 
Nevertheless, the latter is interfered with, and often inhibited, by certain me- 
chanical and chemical influences which afford us protection. The conjunctiva 
is an extremely exposed membrane, which harbors, however, but a relatively 
small number of bacteria under ordinary circumstances. The tears before 
escaping from the conjunctival sac are sterile, and are probably saline enough 
to act as an antiseptic bath for the cornea. Moreover, by free escape of secre- 
tion through the nasal duct the conjunctival sac is kept constantly irrigated, to 
which is mainly due, in all probability, its ordinary healthy condition, since we 
know how commonly lesions follow obstruction to the lachrymal duct. The hor- 
rible results of Egyptian ophthalmia — j. e. the pyogenic form of conjunctivitis — 
are familiar to all travellers in Egypt. This disturbance has by Howe and 
others been clearly shown to be in the main due to the flies which are attracted 
toward the eyes of the infants, and which are most pronounced carriers of infec- 
tion, while the superstitious notions of the parents restrain these children from 
instinctive protection of the eyes when thus irritated. There is probably no 
greater common carrier of pyogenic infection than the common house-fly, and 
nowhere is this agency more abundantly demonstrated than in the hot climates 
of the Orient. 

Upper Respiratory Tract. — The oral cavity and pharynx are never 
free from bacteria. Miller has studied over one hundred species that 
he has found under various circumstances in the human mouth. Some 
of these are pathogenic ; others are apparently absolutely innocent. 
Many of the forms which grow in saliva will not grow in ordinary 
media. ( Vide Plate III., illustrating infection of the teeth.) Miller 
has also shown that all forms of dental caries are but expressions 
of bacterial invasion even of those apparently most solid structures, 
the teeth ; and of late we have been taught more fully that such 
invasion may extend far beyond the confines of the teeth alone, and 
may spread to various, even to distant parts, and produce possibly 
fatal mischief. Abscesses in the brain and extensive septic infections 
have been clearly traced to invasion along the line of the dental 
tubules. One of the most virulent of all the common inhabitants of 
the mouth is the pneumocoecus of Frankel, known also as the micro- 
coccus lanceolatus of Sternberg. In virulence it is a most variable 
organism, but it is present in a virulent state in only 12 or 15 per cent, 
of cases of infection due to it. This is the organism which is the 
cause of lobar pneumonia, and frequently of broncho-pneumonia, as 
well as of numerous phlegmons and other inflammations of the throat, 
and which, getting into the general circulation through the tonsils or 
other possible ports of entry about the mouth, causes serious septic 
and inflammatory disturbances in widely distant regions. Aside from 
dental caries, a widely-opened port of entry is often afforded bv those 
ulcerations around the margins of the gums which are produced by 
accumulations of tartar. Disease in the antrum of Highmore for 
instance, and many other local destructions, are frequently caused in 
this way. 

The next most common port of entry is the ton.v/, which contains 
a variety of crypts which are often filled with secretions or retentions 
loaded with bacteria. And one of the most common sources of an 



PLATE III. 



*> '.'^E«*«^"':-..."a 



■fepai 



s. 







Artificial Dental Caries — Id cross section ; tubules 
filled with bacteria. (Miller.) 





Putrid Tooth Pulp. Infection of Dental Tissue 
(i-iooo.) (Miller.) 



FIG. 4. 






c 



Dental Caries ; disappearance of dental tissues as 
result of presence of bacteria (Miller.) 

FIG. S. 




Dental Caries ; tubules filled with cocci. (Miller.) 
FIG. 6. 







Dental Caries. (1-500.) (Miller.) 



Dental Caries ; tubules plugged with cocci. 
(1-500.) (Miller.) 



IN FLA MM A TION. 53 

infection which leads to involvement of the cervical lymph-nodes in 
tubercular disease is an infection [springing first from the tonsil or 
the teeth. 

In spite of the fact that myriads of bacteria are swept into the 
nasal cavities with the air we breathe, relatively few are met in the nose. 
A peculiar capsule bacillus, closely allied to that described by Fried- 
lander, has been found in a number of cases of ozasna, while the pneu- 
mococcus of Friinkel is also often found there, and is known to produce 
abscesses of the brain. One specific organism — namely, that of rhino- 
xcleroma — concerns the nose almost solely, its first ravages at least 
being met with in this location. 

Alimentary Omal. — Probably more micro-organisms enter the ali- 
mentary canal than gain access in any other way, these coming both 
from food and drink as well as air. Once within its confines, rela- . 
tively very few of them are capable of prolonged existence. Welch 
states that the meconium of new-born infants is sterile, but that within 
twenty-four hours it usually contains abundant bacteria. That bac- 
terial infection through this passage-way is a very fertile source of non- 
surgical lesions is well known. The possibility of surgical infections 
being produced in the same way is both more remote and less demon- 
strable. Naturally, anaerobic organisms find here more favorable 
conditions, and even extremely acid or extremely alkaline conditions 
do not serve to destroy all such life. Pyogenic cocci are often present, 
and are frequently found, in peritoneal exudates. In the intestines of 
herbivorous animals the tetanus bacilli and those of malignant oedema 
are regularly found. The fungus of actinomycosis also easily finds its 
way into the bowel along with ingested food. Under ordinary con- 
ditions the bile in its natural reservoirs is free from bacteria, but the 
colon bacilli and pyogenic cocci often invade these precincts. 

Genito-urhutrif Tract. — Even the healthy urethra always contains 
bacteria. While these may wander upv/ard to an indefinite extent, 
there is every reason to think that the urine contained within the bladder 
in a condition of perfect health is free from bacteria, and that if such 
gain entrance they do not long remain. The same is true of the female 
bladder and urethra. The vagina contains organisms of many species, 
some of which do not grow on ordinary culture-media, but are to be 
recognized by the microscope. While it is quite generally acknow- 
ledged that the vaginal secretion is, as a rule, possessed of bacteri- 
cidal properties, there is as yet no satisfactory nor comprehensive 
explanation of this fact, its normal acidity not being sufficent in 
this direction. 

The Milk in the Lacteal Ducts. — In a condition of perfect health 
milk secreted from the ideal mammary gland is sterile, but may easily 
become contaminated upon its exit from the nipple. Conversely, 
under many favoring conditions these organisms may travel into the 
lacteal ducts from the skin without, and thus contaminate the milk. 
In all probability, the breast corresponds in behavior to other glands 
whose ducts open upon the surface, and, while such openings invite 
entrance of bacteria, their migrations do not extend far from the sur- 
face unless some of the other conditions already mentioned predispose 
to further infection or extension. 



54 SURGICAL PATHOLOGY. 

In summarizing the general topic of possible sources and paths 
of infection we may say that bacteria may enter and exert deleterious 
action — 

A. From within the system ; and 

B. From without. 

A. From within they may get into the tissues either through the 
inspired air, through food and drink— i. e. ingesta— or by means of 
more direct inoculation, as, c. g., by foreign bodies or by venereal con- 
tact. The danger through infection by inspired air is relatively very 
small, and concerns most probably a limited number of organisms, of 
which the tubercle bacillus is the'most important. Foul air and air 
which emanates from sewers, cess-pools, etc., while most unpleasant 
to breathe and deleterious in many other ways, does not necessarily 
contain any micro-organisms which can be injurious. This fact, in 
opposition to generally-received notions, is, nevertheless, proven by 
recent investigations. The ingesta furnish the most fertile source of 
contagion from within, but the diseases thereby produced fall for the 
most part into the domain of medicine rather than that of surgery. 

B. Infection from without the body may come by actual contact 
with previous skin or mucous lesions, and particularly from noxious 
insects and certain parasites. Among surgeons the principal sources 
of contact-infection to be enumerated and guarded against are — 

1. Skin and hair; 

2. Instruments ; 

3. Sponges or their substitutes ; 

4. Suture materials ; 

5. The hands of the surgeon and his assistants ; 

6. Drainage materials; 

7. Dressing materials ; and 

8. From miscellaneous sources — e. g. drops of perspiration, unclean 
irrigator nozzle, a contaminated nail-brush, the clothing of the op- 
erator, etc. 

While insisting here upon the recognition of these sources of dan- 
ger, the precautions to be taken against them are to be considered 
under another heading, to which the reader must at present be re- 
ferred. 

One of the greatest sources of possible infection has of late been shown to 
be the presence of flies and other noxious insects, which act as carriers of infec- 
tion. The Egyptian ophthalmia, which ruins the sight of 30 per cent, of the 
inhabitants of Egypt, has been shown by Howe and others to be due to infection 
by this mechanism ; and a very simple bacteriological experiment will suffice 
to show that the foot-tracks of a single fly across a wound furnish abundant 
opportunities for infection with organisms which are presumably virulent. In 
fact, the danger of carriage of infection by this means is greater than from 
almost all other sources, except the use of improper materials during surgical 
operations. 

Classification of Infections. 

We speak of infections in another way as primary, secondary, and 
mixed ; and it is necessary, for purposes of accuracy at least, to make 
a reasonably clear distinction between them. By primary infection 
is meant infection with a single form of organism whose effects are 



INFLAMMATION. 55 

prompt and speedy. Of this erysipelas or syphilis may serve as a good 
illustration, although in the latter instance the character of the < 'tin- 
tag i am vivum is not yet definitely known. Most of the acute infec- 
tions, in fact, belong to the primary type. 

Secondary infection means that after certain disturbances due to 
a primary infection — i. e. one of a given type — there occurs at some 
later period and from a distinct source another infection whose results 
may be more or less disastrous, and cause the case, at least for the time 
being, to assume a different aspect. W r e may have an illustration of 
this in the case, for example, of primary tuberculosis with distinct 
infection of a number of lymph-nodes, which, acting as filters, have 
caught in their tissue-net a large number of tubercle bacilli that, 
lodging there, have produced the usual well-known results and have 
practically converted the infected nodes into granulomata. In these 
infected masses well-known changes, such as those which follow tuber- 
cular infection — atrophy, caseation, calcification, etc. — may be occur- 
ring, when suddenly there comes infection of a pyogenic type and 
from another source, and suppuration of the granuloma is the result. 
It is possible even to have a tertiary infection, of which the follow- 
ing may be a hypothetical instance : Primary infection with scarlatina 
or measles, by which vital susceptibility is in some instances notori- 
ously lowered ; as the result of this, secondary tubercular infection in 
an individual previously resistant ; and, third, a suppurative infection, 
as above described. 

In contradistinction to these distinct events, separated by an ap- 
preciable, sometimes a considerable, length of time, we recognize a 
mixed infection, where two or more organisms are implanted at or 
about the same time. A very common illustration of this is met with 
in most cases of gonorrhoea, in which there is a synchronous attack 
made by the gonococcus, which is a specific micro-organism, accom- 
panied by staphylococci or streptococci, whose effect will complicate the 
case and make it assume a less particulate type of infection. Mixed 
infections may often occur in other ways, as syphilis and chancroid, 
chancroid and gonorrhoea, etc. Most cases of mixed infection belong 
rather to surgery than to general medicine, and constitute an apparent 
violation of the rule to which physicians often point — that two distinct 
infectious diseases are seldom communicated or acquired at the same 
time. Nevertheless, the facts remain as above. 

Bacteria of Pus-formation. 

Bacteria which act as agents in the formation of pus are collec- 
tively known as pyogenic organisms. These are divided into two 
groups : 

A. The Obligate; and 

B. The Facultative. 

Obligate pyogenic organisms are those whose activity is always 
manifested in the direction of pus-formation, which seem to produce 
it if they produce any unpleasant action whatever. On the other 
hand, the facultative organisms are those which are known occasionally 
to be active in this direction, and yet which are not always nor neces- 



56 



SURGICAL PATHOLOGY. 



sarily so. The members of the group A are fairly well known and 
catalogued, and are not very numerous. On the other hand, there is 
reason to think that many organisms may have the occasional effect 
of producing pus, as it were by accident or at least in a way not abso- 
lutely natural nor peculiar to themselves, but are yet frequently found 
when there is no pus present. A suitable list of the facultative organ- 
isms, therefore, can hardly be made, and will not be here attempted, 
the effort being only to mention the more common organisms which 
play this facultative role. It must be mentioned also that even the 
adjectives " obligate " and " facultative " are to be accepted with some 
mental reservation, since staphylococci, for instance, may be met with 
even in the absence of pus, although nearly all that we know about 
these organisms implies that pus would be the result of their presence 
if one wait. Furthermore, there are certain other organisms, not, 
strictly speaking, bacteria, which also have the power of producing 
either pus or pyoid material. These will also be mentioned in their 
place. Some of them belong not only to the vegetable, but to the 
animal kingdom. 

Obligate Pyogenic Organisms. — A. The staphylococcus pyogenes 
aureus, albu*, citrem, etc. — One of the marked characteristics of the 
staphylococci as a group is the powerful peptonizing action which they 
exert. Moreover, the chemical products of their life-changes seem 
to be more potent both in a local and a general way, leading to greater 
destruction of tissue in their immediate vicinity, with greater inhibi- 
tion of the chemotactic powers of the leucocytes ; that is, with more 
interference with phagocytosis, by which their progress would be inter- 




Fig. 6. 




*&*"3H6 «• 



'^ 



0<. 



Staphylococci in pus ; X 1000 (Friinkel and Streptococci in pus ; X 1000 (Frankel and 
Pfeiffcr). Pfeiffer). 

fered with. Their presence is often to be recognized by a peculiar 
odor, as of sour paste, which when detected should always lead to a 
prompt change of dressings and disinfection of the wound (by irriga- 
tion, spraying with hydrogen dioxide, etc.). 

B. Streptococcus pyogenes and Streptococcus eryxipefatis. — These two 
organisms do not differ in morphology or characteristics, and, while 



INFLAMMATION. 57 

for some time considered as distinct from each other, are now by 
most observers regarded as identical. The streptococci grow in 
chains of variable length, and individual cocci vary in size. They 
grow with and without oxygen, in all media, at ordinary temperatures, 
do not liquefy gelatin, stain readily, sometimes but not invariably 
coagulate milk, and vary very much in longevity. They differ extra- 
ordinarily in virulence as obtained from different sources. 

There are many streptococci not included under the above head which are 
indistinguishable morphologically and in other respects, and yet which are in 
a measure or entirely free from all pathogenic activity in man. A careful bio- 
logical study reveals remarkable and unexplainable transformation in effect as 
between the different members of this species, a part of which may be referable 
to conditions pertaining to the organism infected, but part of which appar- 
ently pertains to the bacteria themselves. It is held by some that scarlatina is 
an invasion by certain organisms of this class ; this, however, is not yet defi- 
nitely established. When found in the stools of children with summer diar- 
rhoeas they are regarded as indicating actual ulceration of the intestinal mucosa. 

In contradistinction to the staphylococci, the streptococci manifest 
a strong predilection for lymph- vessels and lymph-spaces, along which 
they extend themselves with great rapidity. They have much less 
peptonizing power than the staphylococci (except in the absence of 
oxygen) ; hence streptococcus infection assumes usually the type of 
widespread infiltration rather than of circumscribed and distinct 
oedema. One sees remarkable in- 
stances of this in cases of phleg- 
monous erysipelas. It is suggested 
also that the peculiar manner of 
growth of the streptococci, in long 
chains which may coil up and en- 
tangle blood-corpuscles, has much 
to do with the formation of fat- 
emboli and with general pysemic 
disturbances. 

Both these bacterial forms have the 
power of producing lactic fermentation 
in milk ; and it is quite sure that lactic- 
a.cid formation sometimes takes place 
along with suppuration in the human 
tissues, causing acidity of discharge, 
sour odor, and watery pus. It would 

appear also that these two pyogenic „. , , . „,. ^^^^^^^™ 

„rr , , £ 4. ■■ Staphylococcus infiltration of perirenal tissue, 

forms have less power of ptomaine or f rom a case of pyaemia ; x 1000 (Frankel and 
toxine formation than many others, and, Pfeiffer). 
consequently, that the pyrexia attend- 
ing suppuration or purulent infiltration is not always to be ascribed to this 
cause alone, for fever may in some measure be due to tissue-metabolism attend- 
ing their growth, the metabolic products being pyretic. This is in a measure 
substantiated by the fever attending trichinosis, where the question of ptomaine- 
poisoning has not yet been raised. 

C. Micrococcus (anceo/atus, known also as the diplococcus pneu- 
monia, or the pneumococcus of Frankel and Weichselbaum, and as 
the micrococcus of sputum septicwmia of Pasteur and of Sternberg. 
It is of interest to surgeons because it causes many localized inflam- 
mations and is a frequent factor in causing septicaemia ; it is very 
often present in the mouths of healthy individuals. It may produce 




58 SURGICAL PATHOLOGY. 

all the various forms of exudates as the result of congestion set up 
by its presence. It may produce otitis media, meningitis, osteo- 
myelitis, and serious suppurative disturbance in the periosteum, the 
salivary glands, the thyroid, the kidney, the endocardium, etc. 

D. The micrococcus Mragomw. — Suppurations produced by these 
organisms alone are prolonged, mild in character, not painful, but 
accompanied by much brawny induration of tissues. 

E. The micrococcus gonorrhoea, or gonococcus, is found constantly 
in the pus of true gonorrhosa, in many cases the pus being a pure 
culture of this organism. These cocci are always met with in pairs 
(biscuit-shaped), while their inclusion within the leucocytes or their 
attachment in or to epithelial cells is characteristic. 

Unlike all other pyogenic cocci, these do not stain by Gram's method, 
being decolorized by iodine, by which fact they may be distinguished. They 
are cultivated with difficulty, and are known rather by their clinical effects 
than by their laboratory characteristics ; are human parasites, other animals, so 
far as known, being practically immune. The gonococcus may also produce 
abscesses, and may be carried to distant parts of the body, where its effects are 
most commonly noted as pyarthrosis, although endocarditis, pericarditis, pleu- 
risy, etc. are known to be due to it, and fatal pyaemia has been produced in con- 
sequence. In some way, not always clear, it is probably the explanation of the 
post-gonorrhoeal arthritis so often wrongly spoken of as gonorrheal rheumatism. 

F. The Bacillus coli communis or Colon bacillus. — This is an ordi- 
nary inhabitant of the intestinal canal ; varies extremely in virulence 
and somewhat in morphological appearances ; coagulates milk ; is often 
associated with other organisms ; migrates easily both along the ali- 
mentary canal and from it into the surrounding tissues or channels. 
It is a frequent disturbing element in the production of kidney and 
hepatic disease, as also in the production of appendicitis and perito- 
nitis. Ordinarily its pyogenic properties are not virulent ; occasion- 
ally, however, it becomes extremely virulent. 

G. The bacillus pyocyaneus, a widely-distributed organism, often 
met with in the skin and outside of the body ; a motile, liquefying 
bacillus, growing at ordinary temperatures, seldom met with alone, 
but occasionally producing pus without association with other organ- 
isms ; it stains the discharges and dressings a characteristic bluish- 
green and imparts sometimes an offensive odor. 

Suppuration caused by this bacillus is usually prolonged, but characterized 
by little constitutional disturbance. 

Facultative Pyogenic Organisms — i. e. those which have the 
power of provoking suppuration, but which have other and more dis- 
tinct pathogenic activities as well. 

A. Bacillus typhi abdominalis.— -This is found in many pus-foci, developing 
during or after typhoid fever. It is occasionally met with alone, though most 
of these abscesses are really mixed infections. It is most commonly met with 
in the bone or beneath the periosteum. Such abscesses are frequently met with 
in the ribs, and may not be noticed until months after the convalescence from 
the fever. The pus contained within them is not always typical in appearance 
but may be unduly thin or unduly thick. 

B. 'Bacillus protem.— Under this name are included three distinct forms 
which were originally described by Hauser as distinct species, but which are 
now regarded as pleomorphic forms of the same organism. It is a motile bacil- 
lus, met with in decomposing animal and vegetable material, and occasionally 



INFLAMMATION. 



59 



found in the alimentary canal. It has been found to produce pus, especially in 
the peritoneal cavity and about the appendix. It may even cause general infec- 
tion and peritonitis. 

C. Bacillus diphtheria;. — A non-motile bacillus, varying considerably in size 
and shape, changing the reaction in sweet bouillon from acid to alkaline; pro- 
duces a most dangerous infective inflammation of exposed surfaces, with tena- 
cious exudate amounting to a distinct membrane. As a part of its life-history 
it also produces a powerful toxalbumen, which is one of the most profound cell- 
poisons known, the disintegration of the cell-constituents due to its action being 
rapid and pronounced. This will account for the sudden heart-failures which 
are so often reported in connection with the disease. 

D. Bacillus tetani. — More will be said about this organism when consider- 
ing Tetanus, and to that subject the reader is referred. The tetanus bacillus is 
occasionally found in pus which comes from the area through which the orig- 
inal infection was produced. But these bacilli do not travel to any distance in 
the human body, and are practically never found away from the area primarily 
involved. Under most of these circumstances the pus is the product of a mixed 
infection. 

E. Bacillus 02dem.at.is maligni. — This, too, will be more fully considered 
under a different heading. (See Malignant (Edema.) It is a long, anaerobic 
bacillus, widely distributed in the soil and the faeces of animals. There is rea- 
son to think that this, like the tetanus bacillus, may occasionally lead to forma- 
tion of pus. 

F. Bacillus tuberculosis. — This organism likewise will receive fuller descrip- 
tion in an ensuing chapter. (See Tuberculosis.) The pus of old cold abscesses, 
in which the more obligate pyogenic organisms have long since died out, usually 
still contains this organism in mildly virulent form. On the other hand, fresh 
suppurations occurring in connection with tubercular disease are mixed infec- 
tions. There is reason to hold, however, that this organism is capable of pro- 
ducing pus even when none of these are present. For example, in that form of 
acute miliary tuberculosis which is occasionally met with as bone-abscess it may 
be found, for whose origin we naturally look to this organism. 

G. Bacillus anthracis. (See Anthrax.) — This is one of the most malignant 
and resistant organisms known, being in the highest degree poisonous for the 
smaller animals, man being less susceptible. One of its characteristic lesions in 
the human body is a form of pustule commonly known as malignant pustule, the 
pus in which is usually a pure culture of this organism. 

H. Bacillus' mallei. — This is the organism which produces glanders in the 
lower animals and in man. That form 
of the disease which is commonly known 
as farcy, in which the infected nodules 
rapidly break down, is most likely to 
contain pus which shall be more or less 
a pure culture of this organism. 

I. Bacillus lepra. — This is the micro- 
organism which produces leprosy and 
which closely resembles the tubercle 
bacillus. It is constantly and exclu- 
sively present in the lesions in leprosy, 
which are often of the suppurative type, 
the bacilli being enclosed within pus- 
cells, as well as found in the fluid sur- 
rounding them. Although suppuration 
in these cases may be in a large measure 
due to secondary infection, it is positive 
that the leprous bacilli deserve to be 
grouped in this place. 

J. The bacillus pneumonia of Fried- 
lander was at one time regarded as the 
cause of croupous pneumonia, which is 
now known to be due to the micro- 
coccus lanceolatus. The Friedliinder bacillus, however, is capable of pro- 
ducing broncho-pneumonia, and is occasionally met with in empyema, suppu- 



Fig. 8. 




Friedlauder's pneiimococci, from sputum ; 
X 1000 (Frankel and Pfeiffer). 



60 



SURGICAL PATHOLOGY. 



rative meningitis, and inflammations about the naso-pharyngeal cavity, of which 
it is known to be an occasional inhabitant. 

K. The Bacillus of Rhinoscleroma. — A distinctive organism has been described 
for this disease, and given this name. It has such wide morphological differ- 
ences, however, that it is possible that it is only the bacillus of Friedl'ander 
above mentioned. At all events, an organism of this general character is con- 
stantly found in the thickened tissues from the nose in this disease. ( Vide Fig. 10.) 



Fig. 9. 





A 


■ • 9 A 




" ; M 






Rhinoscleroma : infiltration of tissues about the 
nose (case reported by I)r. Weude, Buffalo). 



Bacilli of rhinoscleroma; X 1000 (Frankel and 
Pfeiffer). 



L. The Bacillus of Bubonic Plague. — This was recently discovered by Kita- 
sato, and, in view of the recent ravages of the disease in the Orient, has. as- 
sumed considerable importance. It grows upon most media, and is found in the 
blood, in the buboes, and in all- the internal organs of patients suffering from 
this disease. The smaller animals are susceptible upon inoculation. Animals 
fed with inoculated foods die also, showing the possibility of infection through 
the intestine. When exposed to direct sunlight for a few hours the bacillus 
dies. The general expressions of the disease are those of hemorrhagic septicaemia 
and its consequences. 

M. The Bacillus of Rauschbrand. — This is seldom, if ever, seen in this country. 
It is known in England as " the black-leg" or " quarter-evil." It is an anaerobic 
organism, frequently met with in cattle, which causes a peculiar emphysema of 
subcutaneous tissue, which spreads more deeply, and is followed by a copious 
exudate of dark serum with gas-formation. The smaller animals are not ordi- 
narily inoculable ; but, if to the culture-material used be added 20 per cent, of 
lactic acid, their insusceptibility is overcome and they succumb quickly to the 
disease. So also, as in the case of the tetanus bacillus, by addition of the bacil- 
lus prodigiosus or of proteus vulgaris the disease may be induced in otherwise 
insusceptible animals. 

Fungi. 

Besides the micro-organisms everywhere grouped as bacteria, there are other 
minute organisms which have also the power of engendering pus. One of these 
is the ray-fungus, known as the act inomycis, which causes the disease known as 
lumpy jaw or actinomycosis. Suppuration is always a concomitant of the ad- 
vanced lesions of this disease, and, while it may be in many instances a mixed 
infection, it is not necessarily so. Moreover, the pns produced under these cir- 
cumstances contains minute calcareous particles which are pathognomonic, and 
by which a diagnosis can sometimes be made off-hand. 

Besides these fungi, others, belonging rather to the class of vegetable moulds, 
which are yet pathogenic for human beings, may be occasionally met with under 
these circumstances— for example, the fungus of Madura-foot, the leptothrix, and 
other moulds from the mouth, while the different varieties of aspergillus may be 
found in pus about the ear, or even in that from the brain. 



INFLAMMATION. 61 



Protozoa. 



The protozoa also have the power occasionally of producing, if not absolute 
ideal pus, something so strongly resembling it that we may include them among 
the facultative pyogenic organisms. The best known of these protozoa are the 
amcebce which are so often met with in the intestinal canal in certain countries, 
and which are occasionally met with in the United States, especially as the 
exciting causes of a peculiar type of dysentery often accompanied by abscess of 
the liver. In these abscesses the amoebse are usually found, and no other organ- 
isms. Another group of the protozoa, known to biologists as the coccidia, are 
also capable of causing pus-formation, more particularly in some of the lower 
animals. Numerous other parasites, belonging higher in the animal kingdom, 
are undoubted exciters of pus-formation, though it is not necessary to lengthen 
the list beyond those already mentioned. 

Clinical Characteristics of Pus from Different Agencies. 

Staphylococcus. — Dirty white, moderately thick, with sour-paste 
odor. 

Streptococcus. — Thin, white, often with shreds of tissue. 

Colon Bacillus. — Thick, brownish, with fetid odor, or thin, dirty 
white, with thicker masses. 

Micrococcus Lanceolatus. — Thin, watery, greenish, often copious. 

Bacillus Pyocyaneus. — Distinctly green or blue in tint. 

Bacillus Tuberculosis. — Thick, curdy, white paste, or thin, green- 
ish, with small cheesy lumps or even with bone-spiculse. 

Actinomycis. — Thick, brownish white, with small firm nodules of 
yellow color. 

Amozba Co/i. — Thick brownish-red. 

Bacterial, Determination as an Indication in Treatment. 

There is a practical side of great importance pertaining to the 
recognition of the nature of the infectious organism in many cases of 
suppuration and abscess. For instance, pus which is due to strepto- 
coccus invasion indicates a collection which should be freely evacu- 
ated and carefully drained. This is also true in essential respects of 
staphylococcus pus, particularly that due to the S. aureus. Putrid 
pus from any source calls for disinfection and free drainage, the 
former preferably perhaps by hydrogen dioxide. Pus which is due 
to the colon bacillus is not often extremely virulent, which accounts 
for so manv cases of appendicitis recovering with or without opera- 
tion. A collection of this pus calls for little more than mere drain- 
age and opportunity for escape. Pus from a recognizable tubercular 
source may still contain living tubercle bacilli. This means either 
that the cavity whence it came should be completely destroyed and 
eradicated, or else that the margins of the incision or opening through 
which it has escaped should be so cauterized that infection of a fresh 
surface is impossible. The same is true of abscesses due to glanders 
bacilli and to certain cases of suppurating bubo following chancroid, 
where the whole course of events shows the virulent character of the 
organisms at fault. 

Suppuration. 

Although it may be possible to produce in certain laboratory ex- 
periments metamorphosed material which very closely simulates pus, 



62 SURGICAL PATHOLOGY. 

or, in fact, by injection of chemical irritants, to sometimes quite faith- 
fully imitate the suppurative processes, nevertheless, the student 
must be promptly brought face to face with the statement, to which 
for surgical purposes there is no practical exception, that suppura- 
tion — i. e. formation of pus — is due to the presence in the tissues 
of the specific irritants already catalogued and described, and of 
the peculiar peptonizing or other biochemical changes which bacteria 
exert upon living animal cells. Coagulation-necrosis is the term 
applied to the characteristic changes occurring in the tissue-cells 
when thus attacked, which may be summarized as a fading away of 
cell-outlines, diminution in reaction to reagents, and a sort of merg- 
ing together of cells and intercellular substance. Coagulation- 
necrosis is not the sole result of bacterial activity, but may be brought 
about from other causes. Nevertheless, pyogenic bacteria do not 
exert their deleterious action upon the tissues without bringing about 
changes included under this term. In an area thus infected, as 
already described, leucocytes — i. e. phagocytes — are present in largely 
increased numbers for purposes already distinctly described. As we 
get nearer to the centre of activity phagocytes are more numerous 
than are cells, and intercellular barriers completely break down. 
Where bacteria are found in greatest numbers, there also occurs the 
greatest phagocytic activity, and there too will be found the charac- 
teristic evidence of suppuration — i. e. pus. As already indicated, the 
poly nuclear leucocytes are most active of all in the process of defence. 
Where coagulation-necrosis is most marked there has been the 
greatest activity of conflict with the greatest death of cells. Around 
these areas bacteria and cells are found in indiscriminate arrange- 
ment. Tissue-vitality is impaired by intoxication of the cells by the 
excretory products of the bacteria — i. e. the so-called ptomaines, 
toxines, etc. — and their power of resistance is thus weakened. From 
the mechanical results of pressure tension around the centre of 
activity is increased ; by which tension vitality is still more impaired 
and more rapid tissue-death occurs. Thus there occurs migration or 
burrowing of pus ; or, to put it more clearly, the tissues break down 
in front of the advancing destruction, and always in the direction of 
least resistance. This is known as the pointing of pus, and this it is 
which brings it many times to the surface, and often in other and 
less desirable directions. 

Abscess. 
An abscess is a circumscribed collection of pus. The term is 
used in contradistinction to purulent infiltration, in which the collec- 
tion is by no means circumscribed, but is exceedingly diffuse and 
extends itself in various directions, the amount at any particular 
spot being almost inappreciable. Purulent infiltration is commonly 
regarded as much the more serious of the two conditions, since it is 
much harder for pus to safely escape under these circumstances than 
when it can all be evacuated through a single opening. The term 
phlegmon _ is ^one which is now generally used, both at home and 
abroad, to indicate a suppurative process usually of the general cha- 



PLATE IV. 




3r-. 



bseess in Kidney of Rabbit after Intravenous Injection into an 
Ear-vein of Culture of Pyogenic Cocci. Dense mass of cocci 
surrounded by area of coagulation necrosis due to their toxic 
activity. Outside this a zone of phagocytes. 



INFLA MM A TION. 6 3 

racter of purulent infiltration rather than of abrupt abscess, but some- 
what generally employed to cover both conditions. The adjective 
phlegmonous is coupled with the name of any of the other surgical 
infectious diseases to indicate that it is complicated by suppuration — 
c. g. phlegmonous erysipelas. Pus is a product of bacterial activity 
which is usually formed rapidly rather than slowly, and abscess- 
formation or phlegmonous activity of any kind is ordinarily a matter 
of but a few days. 

In connection with this I would like to summarize the story of 
inflammation and suppuration, to paraphrase Sutton, and read it 
zoologically, as though it were the story of a battle. The leucocytes 
(phagocytes) are the defending army, the vessels its lines of communi- 
cation, the leucocytes being, in effect, the standing army maintained 
by every composite organism. When this body is invaded by bacteria 
or other irritants, information of the invasion is telegraphed by means 
of the vasomotor nerves, and leucocytes are pushed to the front, rein- 
forcements being rapidly furnished, so that the standing army of 
white corpuscles may be increased to thirty or forty times the normal 
standard. In this conflict cells die, and often are eaten by their 
companions. Frequently the slaughter is so great that the tissues 
become burdened by the dead bodies of the soldiers in the form of 
pus, the activity of the cells being proven by the fact that their proto- 
plasm often contains bacilli in various stages of destruction. These 
dead cells, like the corpses of soldiers who fall in battle, later become 
hurtful to the organism which, during their lives, it was their duty to 
protect, for they are fertile sources of septicaemia and pyamia. This 
illustration may seem a little romantic, but is warranted by the facts. 

Around the margin of the site of an acute abscess is formed a 
barrier, by condensation and cell-infiltration of the surrounding tissues. 
This is not a distinct wall nor membrane, yet, nevertheless, serves as a 
sanitary cordon to confine the mimic conflict within reasonable bounds. 
This is the zone of real inflammation ; within it there are tissue- 
destruction and coagulation-necrosis. (Vide Plate IV.) By virtue 
of the peptonizing power of the pyogenic organisms the parts involved 
in this necrosis gradually liquefy, the intercellular substance dissolv- 
ing first. It is this which in the main forms the fluid portion of the 
pus. Various tissues show widely differing resistance to this soften- 
ing process. In true glands the interlobular septa seem to break 
down first, and in this way suppuration extends around the acini or 
gland-lobules, and thus pus may contain masses of easily recognizable 
size. These masses are ordinarily known as sloughs. 

It is by virtue of the so-called lymphoid cells, which are those 
principally involved in producing the barrier or boundary of the acute 
abscess as above described, that granulation-tissue is formed, which 
promptly takes up the effort of repair so soon as pus is evacuated. 
This boundary has no sharp limit, but shades off into healthy sur- 
rounding tissues. 

Under the term "abscess" is ordinarily meant that which is more minutely 
described as acute abscess. Under certain circumstances, especially where they 
are produced by the facultative pyogenic organisms rather than the obligate, 
abscesses form much more slowly, and may be spoken of as subacute. These are 



64 SURGICAL PATHOLOGY. 

terms used in contradistinction to the so-called cold abscess, which, although clin- 
ically bearing a certain resemblance to the acute, is in almost every pathological 
respect widely different from it. Cold abscesses will be considered at length 
under the head of Tuberculosis. It is possible to have an acute pyogenic infec- 
tion of a cold abscess ; in such case we have acute manifestations. Gravitation- 
abscesses are those where pus forming in one part tends to migrate, usually in the 
direction in which gravity would take it, extending into portions deeper or lower 
down. Perhaps the best illustration of this is the pointing of a psoas abscess 
below Poupart's ligament. Metastatic abscesses are those which are formed as 
the result of embolic processes, each one being in miniature a repetition of a 
lesion which has already occurred at some other part of the body. The under- 
lying fact concerning metastatic abscesses is that the primary process has 
occurred in some other portion of the body, whence it has been distributed 
as above. These will be more fully considered in the chapter dealing with 
Pyaemia. 

The characteristic product of all acute suppurative lesions is pus. 
This is an opaque fluid of creamy consistence and whitish or grayish 
appearance, varying somewhat in density, met with in amounts from 
a minute drop to collections of half a gallon or even more. Under 
ordinary circumstances it is odorless, and its reaction, either acid or 
alkaline, very faint. It is, like the blood, composed of a fluid and a 
solid portion. The solid portion consists of so-called pus-corpuscles 
and other debris of tissue, which will vary with the site of the disease 
and the parts involved. The source of the pus-corpuscles has already 
been cited at length, and the statement already several times made 
that they are in effect the bodies of phagocytes which have perished 
in the biochemical fight for existence of the parent organism. In 
them may frequently — almost always, in fact — be seen cocci or bacilli, 
which are also found in large quantities in the surrounding fluid. 

Pus should be ordinarily without odor, but under certain circumstances it 
possesses an odor which will vary in character according to the source of the pus 
or the nature of its principal bacterial excitant. Pus from the upper end of the 
alimentary canal frequently has the sour smell so characteristic of gastric con- 
tents ; that from the neighborhood of the lower end, the characteristic fetid odor 
which is for the most part due to the action of the colon bacillus. Inasmuch as 
this colon bacillus is found in widely distant parts of the body, it may also give 
unpleasant odor to pus even from a brain-abscess. When the pus has become 
contaminated by any reason with the ordinary saprophytic organisms, it may 
smell like any other decomposing material. The older writers used to speak of 
this as ichorous pus, while sanious pnswa.fi supposed to be that more or less mixed 
with blood, undergoing ammoniacal decomposition or else strongly acid. Pus 
sometimes has a well-marked blue or bluish-green tint. This is clue to the pres- 
ence of the bacillus pyocyaneus, already described. An orange tint is sometimes 
given by the presence of hasmatoidin crystals, due to the original hemorrhagic 
character of the infected exudate. The former appearance indicates usually a 
discouragmgly slow course to the suppurative lesion, while the latter has been 
regarded by some as affording an unfavorable prognosis. Distinctly red pus 
whose tint is due to the presence of a bacillus giving bright-red cultures on 
blood-serum, has been noted in other instances. This can readily be distin- 
guished from blood, because upon dressings it does not change color. 

Pus may form quite superficially, when we speak of it as a sub- 
cutaneous suppuration, in which case there is a minimum of pain, 
because tension is not great and because the distance to the surface is 
short. Collections which form beneath the fasci*, especially the deeper 
fascia; of the limbs and trunk, give rise to much more extensive dis- 
turbance, both locally and generally, and frequently do not point for 
many days, or, instead of pointing, burrow deeply and find their out- 



IS FLA MM A TION. 6 5 

let at some undesirable point. These are known as subfascial collec- 
tions. Subperiosteal abscesses give rise to still more pain, because of 
the unyielding character of their limiting structures, and the symp- 
toms caused by them are often very acute and very distressing. 

An illustration of the pain and disaster which may follow deep suppuration 
may also be seen in the ordinary panaritium or bone-felon, where the path of 
infection is from without, but the destructive lesion is confined within absolutely 
unyielding tissues, at least at first. Along certain tissues infection spreads with 
amazing rapidity. This is particularly true of the delicate areolar tissue met 
with between tendons and tendon-sheaths, and the infectious process may follow 
this tissue wherever it shall lead, even along complex courses. 

The question is often raised, Can pus be resorbedf There is no 
question but what under many circumstances small amounts of pus 
are disposed of by phagocytic activity, and the disappearance of puru- 
lent infiltration under the influence of favoring remedies, or even 
when left alone, is not infrequently noted. True pus-resorption is 
entirely a question of phagocytic possibilities, and can only occur in 
very limited degree as a result upon which it is not safe to count, and 
which is capable of encouragement only up to a certain point. 

One inevitable law seems to govern collections of pus, and that is, 
that when they advance or migrate in any direction it is always in that 
of least resistance. This causes it to take peculiar and sometimes dis- 
astrous courses, but it is a law which is virtually never violated. It 
leads, for instance, to the bursting of abscesses into the brain, into the 
pleural cavity, into the peritoneal cavity, the bowel, and elsewhere ; it 
leads to a condition where pus may travel slowly along a path even a 
foot or more in length, rather than come directly to the surface, a dis- 
tance of perhaps an inch, and affords one of the best reasons for early 
operative interference in order that the disastrous effects of burrowing 
may be obviated. When the collection of pus is limited to a drop or 
a fraction thereof, the little abscess is usually spoken of as a furuncle, 
especially when in the skin. The average " boil " of the layman is a 
subcutaneous or subfascial abscess near the surface. When the infil- 
tration is pronounced, and when there has been more or less extensive 
destruction of tissue, with perhaps formation of numerous outlets for 
the desired escape of pus and detritus, we have what is known as a 
carbuncle; all of which will be of treated in Chapter XXVI. In 
certain peculiar conditions small superficial furuncles or boils form, 
sometimes in great numbers and almost synchronously, or, as it 
were, in crops. This condition is spoken of as general furunculosis. 

Signs and Symptoms of Abscesses. — The appearances by which 
the presence of pus may be suspected or detected are those of conges- 
tion and hyperemia, more or less abruptly circumscribed and markedly 
accentuated. Along with these there is more or less oedema or oedem- 
atous infiltration of the skin and overlying tissue, which permits of 
that peculiar appearance known as " pitting on pressure." Often, too, 
there is a distinctly (Edematous swelling of the parts, especially around 
the margin, with brawny infiltration of the centre of the infected area. 
Numerous vesicles occasionally are noted upon the skin, which may be 
filled with reddish serum. As softening and actual pus-formation 
occur, we get a condition which to the palpating fingers gives the cha- 
racteristic sensation known as fluctuation. Fluctuation ordinarily 



66 SURGICAL PATHOLOGY. 

simply points out the presence of fluid beneath ; but when in an area 
marked as thus described fluctuation is noted, it practically always 
means the presence of pus beneath. It is best detected by manipulat- 
ing in a direction parallel to and concentric with the axis of the limb 
or part. The pain is also significant in most instances : patients speak 
of it, ordinarily, as having an intense and throbbing character. Along 
with these local signs occur often more or less reliable symptoms indi- 
cating some degree of septic intoxication — i. e. pyrexia, chills, malaise, 
sweats, etc. — which are always corroborative indications, their inten- 
sity being a reasonably correct index of the severity and gravity of the 
local infection. 

It is but seldom that a superficial collection of pus can ever be mistaken for 
anything else. In small and superficial abscesses (boils, furuncles) as pus ap- 
proaches the superficial layer (epidermis) of the skin it may often be discovered 
through its thin covering. In deeper lesions there is often room for honest 
doubt, even on the part of the most experienced. The measure now usually 
resorted to for purposes of diagnosis and exact recognition is the exploring or 
aspirating needle. The old exploring needle was one of good size, having a 
groove along which, after introduction, pus might pass. Since the common and 
every-day use of the hypodermic syringe, a small aspirating needle attached to 
the ordinary syringe is now the measure commonly adopted. Such a needle may 
be introduced into the brain, into the liver, or into almost any and every soft 
tissue without danger, and if properly manipulated is almost sure to facilitate 
detection of pus. Exploration done with either of these means and for this pur- 
pose should always be conducted as an aseptic, even if a minor operation, in order 
that no extra infection may be added from without. The skin should be care- 
fully washed, the needle sterilized, etc. 

It is often good surgery to resort to the knife either for the above 
purpose or in order that by a longer incision or by the opening of the 
cavity deep exploration may be made. Such explorations are usually 
of benefit even though one fail to find a circumscribed collection of 
pus, since by relief of tension and local abstraction of blood they act 
in a revulsive way and do much good. Acting upon the same prin- 
ciple, one may use the trephine or the bone-chisel for the purpose of 
opening the cranium and exploring for deep collections of pus, or of 
opening into the medullary canal of the long bones and hunting there 
for that which we have reason, from external appearances, to suspect. 

Treatment. — So soon as suppuration threatens, one should adopt 
speedy measures, either for the purpose of bringing about resorption, 
if possible, or of favoring and hastening suppuration. In theory anti- 
septic applications are demanded ; in practice they are sometimes of 
benefit. These may consist of mere soothing applications, like the 
lead-and-opium wash of our forefathers, or some other wet or dry 
astringent applied upon the surface, or they may consist of cold appli- 
cations, which by their astringent action shall limit the amount of 
exudate and possibly prevent its further infection. Or, as is the cus- 
tomary practice everywhere, one may take advantage of the well-known 
properties of moist heat, and by the application of hot poultices or 
fomentations may encourage exudation, but particularly hasten super- 
ficial breaking down, and thus hurry that desirable time when the 
abscess shall point, or at least shall come near enough to the surface 
to plainly show that its contents are pus, and to permit of easy evacu- 
ation. Such local applications, therefore, give relief from pain and 



INF LA MM A TION. 6 7 

hasten favorably the suppurative process. In cases of phlegmonous 
infiltration I favor, above all other measures, the application of an 
ointment composed of resorcin 5, ichthyol 10, mercurial ointment 35, 
and lanolin 50 parts. Under the influence of this antiseptic and sor- 
befacient preparation, and of moist heat, one may see many phleg- 
monous infiltrations assume a kindlier type, and may even perhaps 
secure the actual resorption of pus. 

Finally, in almost every case the time comes when pus must be 
evacuated. Here, again, the universal rule may be laid down to 
which there are practically no exceptions. This needs to be deeply 
stamped on the mind of every student and young practitioner. It 
is — that pus left to itself will do more harm than will the knife of the sur- 
geon if judiciously used for its evacuation. All action take in accord- 
ance with this rule may be considered wise and timely. The operation 
of evacuation may at one time be a mere puncture, or possibly the 
aspirator needle alone will be enough ; at other times it requires ex- 
tensive and careful dissection and entails no little responsibility. 
This is particularly true in such deep-seated suppurations as those 
around the appendix and in the brain, while in deep-seated bone- 
lesions of this character the extensive use of the bone-chisel or the 
cutting forceps will be called for. But the rule holds good, no mat- 
ter where the pus may be, and so long as good judgment be shown in 
the operative procedure nothing but good can come from recognition 
of this law. After the evacuation of pus the cavity should be cleansed 
so far as circumstances permit, and disinfected with hydrogen dioxide, 
perhaps even with caustic pyrozone, or, if these be not at hand, with 
other suitable antiseptic solutions. 

Ordinary judgment should be manifested in evacuating every 
abscess, in order that opening be made at that point which in the 
common position of the body shall be most favorable to drainage by 
mere gravity alone. If circumstances compel opening where advan- 
tage cannot be taken of gravity, then one or more counter-openings 
must needs also be made, these at points to be selected where drainage 
may be best effected, and at the same time where anatomical conditions 
do not make it injudicious to incise. Drainage must, furthermore, be 
favored by the introduction of drainage tubing or of other aids, 
such as gauze, strands of catgut, bundles of horse-hair, etc. Finally, 
a dressing must be applied which shall be both protective and absorb- 
ent, and in quantity sufficient to make compression of the walls of 
the abscess-cavity — not sufficient to obstruct drainage, but enough 
to favor prompt adhesion of surfaces, which by speedy granulation 
shall ensure prompt healing. 

Certain abscesses are so located in proximity to large vessels or dangerous 
anatomical regions that the greatest care must needs be exercised in opening 
them. Here much better than the bold incision is the careful dissection made 
under an anaesthetic. This may be true of abscesses in the neck ; it certainly 
is true of those around the appendix ; for example, where the general peritoneal 
cavity is only shut off by more or less delicate adhesions, and where one must 
literally feel his way with great precaution lest adhesions be torn and the pre- 
viously protected cavity be infected. At other times, especially in abdominal 
abscesses, it is necessary to pack sponges or absorbent gauze in and about the 
parts in such a way that any fluid which may inadvertently or necessarily escape 
shall be caught by these dressings and thus kept out of harm's way. 



68 



SURGICAL PATHOLOGY. 



Accompanying Disturbances.-The disturbance of function 
which accompanies all congestion and exudation, whether provoked 
by specific irritants or not, has already been alluded to ; but in cases 
of surgical infections, especially those which produce local suppura- 
tion, disturbance of function is much greater, while there are other 
more, widespread disturbances which sometimes constitute the worst 
feature of these cases. The presence, of pus is often indicated, espe- 
cially when deeply seated, by one or more chills, and the occurrence 
of a chill is alwavs marked by pyrexia to varying degree, it is 
correct to say that the chill is an expression of a general septic dis- 
turbance; but it is necessary also not to forget that general septic 
disturbance is a frequent accompaniment of pus which is not promptly 
evacuated so soon as formed. Moreover, in certain cases suppuration 
and septic infection seem to occur synchronously, one being local, the 
other general. 

The other general disturbance, or perhaps the most widespread 
general disturbance with which suppuration is so often complicated, 
is septic infection. In fact, it mav be questioned whether pyrexia is 
not really an expression of this condition. With the general state- 
ment that any collection of pus, no matter how small, may cause 
recognizable signs of septic infection, and that, on the other hand, 
large collections may be formed without serious septic symptoms — 
in other words, with'the statement that suppuration and expressions 
of septic infection may be blended in almost every conceivable way — 
the further consideration of sepsis as a distinct condition will be 
relegated to another chapter. 

It is important to summarize what may become of pus when once it has 
formed and is not promptly evacuated. Without going freely into the subject, 
pus may when long present be — 

A. Absorbed. 

B. Encapsulated. 

0. Undergo various degenerations or chemical alterations. 

A. The possibility of the absorption of pus, or, what is equivalent to it, its 
spontaneous disappearance, has already been mentioned. While it does not 
usually take this course, it may thus disappear, as, for instance, in the anterior 
chamber of the eye in cases of hypopyon, or in various other localities, particu- 
larly when present only in small amounts. The absorption of pus is purely a 
matter, so far as we know, of phagocytic activity plus the power of the tissues 
to take up various fluids. 

B. Encapsulation. — This only occurs when pus has been present for some 
time and when the virulence of the pyogenic organisms is not intense. We 
may get encapsulation of pus in any part of the body, the most typical illustra- 
tion naturally being within the bones. Around the purulent focus, as around 
any other irritating foreign body, the capsule is formed by condensation of sur- 
rounding tissue. This is, in fact, the way in which most cold abscesses with 
their limiting membranes are produced, those produced by tubercle bacilli 
having ordinarily relatively slight irritating properties. Inasmuch, then, as 
the biological activity in such a focus is small, there is time for such encapsula- 
tion ; while by the membrane thus formed, or the sanitary cordon as I have 
already spoken of it, protection is afforded to the surrounding tissues. In such 
a collection fresh infection may incite acute disturbances again, and many 
abscesses which thus lie latent for considerable lengths of time are fanned, as it 
were, into a conflagration, when a new and acute inflammation is produced. 

0. Of the various metamorphoses and chemical changes that occur in that 
which was originally pus, the caseous and the calcific are the most common. 
These also are connected largely with the tubercular process, although calcare- 



IN FLA MMA TION. 6 9 

ous particles are met with in the pus of actinomycosis. Under their respective 
heads these degenerations will be more particularly described. 

Certain particular names have been given to collections of pus in 
particular localities or under peculiar circumstances. A collection of 
pus in the anterior chamber of the eye is known as hypopyon; when 
in any pre-existing cavity, it is known as empyema of that cavity, the 
distinction between empyema and abscess being that " abscess " means a 
circumscribed collection where previously there was no cavity, while 
" empyema " implies a normal cavity, without respect to size or loca- 
tion, filled with this abnormal fluid. By common consent, without 
other authority than common usage, the term empyema, when not 
used in connection with some particular cavity, is understood to refer 
to a collection of pus in the pleural cavity. Other names are also 
used which are particulate and distinctive ; in these the prefix pyo- is 
used, while the suffix indicates the part involved : thus we have 
pyothorax, pyopericardium, pyarilwosis, etc. 

Sinus and Fistula. 

These are terms applied to more or less tubular channels abnorm- 
ally connecting various parts of the body, or connecting some cavity with 
the surface of the body in a way anatomically quite abnormal. Or they 
may be regarded as tubular ulcers, or ulcerated tunnels, connecting as 
above. A more exact distinction between the two terms would imply 
that a sinus connects the surface with some deeper portion where 
a cavity is not normally present — i. e. with a focus of disease ; whereas 
a fistula properly refers to a tubular passage connecting natural or 
pre-existing cavities in an abnormal manner. Thus, we speak of 
buccal, rectal, vesico-vaginal fistulse, etc., whereas a passage leading 
down to an old abscess or to a focus of disease in bone, for instance, 
is properly spoken of as a sinus. It is possible for the margins of a 
fistula to become more or less cicatrized and to cease to be ulcerous ; 
whereas the entire track of a sinus is practically a continuous ulcer, 
only tubular in arrangement. 

Causes. — A. Congenital. — There are numerous points about the 
body where, as the result of arrest of development or failure to grow, 
fistulous passages which are comprised within the normal foetal 
arrangements, but which should close later, either before or at birth, 
fail to do so. In this way we get, for example, congenital fistulse of 
the neck, persistent urachus, persistent omphalo-mesenteric duct, 
etc. These are in no sense primarily connected with diseased condi- 
tions, but may become so secondarily. 

B. Pre-existing abscess with unhealed channel of escape — e. g. 
rectal, fecal, and other fistulas and sinuses which connect with tuber- 
cular foci in any part of the body. 

C. Previous traumatic or other destruction of normal tissues, as, e.g., 
vesico-vaginal fistulse due to tissue-death from pressure, buccal fistulse 
from gangrene of the cheek, as in noma. 

D. Foreign bodies — bullets, ligatures, etc. — which prove irritating 
or infectious enough to prevent absolute healing. More or less tortuous 



70 SURGICAL PATHOLOGY. 

sinuses will almost always be found leading down to the irritating 
material. 

E. The presence of necrosed or necrotic material, as, for example, a 
sequestrum in bone, which is usually evidenced by the presence of one 
or more sinuses. 

Treatment. — If the determining cause be still acting, the treat- 
ment is practically summed up in the advice to remove the cause. 
Consequently, when the sinus leads down to diseased bone or other 
dead or dying tissue, the complete evacuation of the cavity is neces- 
sary before the sinus may heal. If the cause be a foreign body, its 
removal should be at once insisted upon. 

Fistuhe of congenital origin and those which connect two normal 
cavities of the human body are usually due to a cause which has ceased 
to act. Consequentlv, one here endeavors solely to atone for the re- 
sult. One may acquaint himself with the direction and, in a general 
way, with the course of a sinus by the use of a probe curved to suit 
the case and manipulated by a gentle hand, force never being required. 
Or sometimes, when the silver instrument fails to pass, a flexible 
bougie or catheter may be introduced. Information is thus gained as 
to the direction and extent. This information, however, is of less 
value than is ordinarily esteemed, since the character of the passage 
can be for the most part judged by the appearance of the discharges. 
With sinuses of recent origin leading down to recent suppurative foci 
it may be enough to enlarge the opening and to wash out thoroughly 
the cavity as whose exit it serves. If, as sometimes happens, a par- 
ticle of gauze, tube, or sponge have been left therein, its removal is 
probably all that is necessary to secure prompt healing. In cases of 
longer standing it is good practice often to inject antiseptic and stimu- 
lating substances, or even to cauterize the interior by means of strong 
solutions or by means of zinc chloride or silver nitrate melted upon 
the end of a probe. The chronic sinus, as well as the chronic rectal 
fistula, is almost invariably an expression of local tubercular disease. 
Accordingly, these passages will be found lined with the same dense 
fungating membrane which lines a cold abseess-cavitv — the membrane 
protective in its purpose, to which I have given the name pyophylactic. 
Whenever such tissue and such membrane are met with, thev should 
both be extirpated as thoroughly as possible, since in this wav onlv 
can absolute eradication of the tubercular infection be relied" upon. 
After such complete excision — which means usually laying open the 
entire sinus — the parts may perhaps be brought together with sutures 
(this, at least, is usually possible about the rectum) in such a wav as 
to secure primary union; otherwise, the whole sinus, as well as the 
cavity to which it has led, must heal by the granulating process, both 
being kept packed with gauze or some other desirable foreign body 
which shall act as an irritant, thereby provoking more rapid forma- 
tion of granulation-tissue. When it is necessary thus to pack a 
cavity, or when it is desired to keep its upper exit open lest it heal 
before the lower part, ordinary white beeswax, as suggested bv Gunn 
makes a very serviceable material. This can be moulded in hot water 
to fit the cavity, can be tunnelled or bored for drainage, can be dimin- 
ished in size as the cavity heals, and is absolutelv non-absorbent. 



INFLAMMATION. 71 

Finally, there are numerous plastic methods which have been re- 
sorted to in various parts of the body, most of which are made to 
comprise, first, the absolute eradication of the diseased tract, and, 
later, the closure of the wound, thus made, by transplantation or slid- 
ing of flaps or any other plastic expedient which may be considered 
best. These, as well as the special treatment made necessary for par- 
ticular forms of sinus and fistula, will be dealt with more at length 
under their proper headings. 



CHAPTER IV. 

ULCER AND ULCERATION. 

By Roswbll Park, M. D. 



The term ulcer pertains to surfaces/and should be defined as a sur- 
face which is or ought to be granulating — i. e. healing. 

While an ulcer may be the result of what is known as ulceration, it 
is by no means necessarily so, the term ulceration being one of very loose 
significance and applied to many different processes. For our present 
purposes the idea underlying ulceration is infection, and, when limited 
to its proper significance, the term should never be used for a process in 
which infection and consequent breaking-down of tissue do not virtually 
comprise the whole process. In this regard, therefore, it is to be abruptly 
distinguished from certain disappearances of tissue already alluded to 
under the head of Atrophy or Interstitial Absorption. It is therefore 
not correct to say that the sternum ulcerates away, making room for a 
growing aortic aneurism, the question of infection not here being raised. 
These distinctions should be accurately maintained and constantly borne 
in mind. 

Ulcers. 

The causes of ulcers may be — 

A. Traumatic ; 

B. Local; or, 

C. Constitutional. 

A. Traumatic. — This would include all those surfaces which are 
granulating and healing more or less rapidly, or are displaying, in other 
words, a kindly disposition toward healing, and which may have been 
originally produced by wounds, burns, frost-bites, etc. These include 
also those ulcers which are due to pressure, as from splints, bandages, 
various orthopaedic apparatus, or from external friction. Ulcers which 
form around foreign bodies may also be included under this head, their 
essential cause being traumatic. 

This should include also destruction of the surface by various chem- 
ical agencies, such as strong caustics ; also the consequences of intense 
heat or cold, including particularly burns and frost-bites. 

B. Local.— 1. Among local causes may be mentioned local infec- 
tions with tissue-death in consequence, such as occur in tuberculous 
leprous, syphilitic, and other specific manifestations where surfaces are 
involved. 

72 



ULCER AND ULCERATION. 



73 



2. Tumors, either benign or malignant, whose blood-supply is cut off 
and whose surface is thereby predisposed to infection. 

3. Perverted surface-nutrition, such as is most commonly met with, for 
example, in connection with varicose veins of the extremities, where, 



Fig. 11 




Chronic ulcer of leg. 



aside from any perverted trophoneurotic influence, there is stagnation of 
blood, saturation of tissues with serum, and final leakage of the same, 
even to the surface. In other words, a passive hypersemia leads here 
to oedema, perversion of nutrition, failure to repair trifling surface-injury, 
and a commencing ulcer is the consequence. 

4. So-called pressure-sores or bed-sores, which in some cases may be 
regarded as having a traumatic origin, but which, nevertheless, would 
not occur from purely traumatic influences without predisposing tissue- 
changes. The bed-sore is probably the best illustration of this. Simple 
ulcer is known as bed-sore, while a sloughing ulcer of this kind is fre- 
quently alluded to as decubitus. Such ulcers are usually found over those 
regions of the body made most prominent by bony projections, upon 
which undue pressure is made when debilitated patients have lain for 
a long time in bed. 

5. Ulcer is the frequent result of numerous skin diseases, into whose 
etiology as yet bacteria have not been introduced — e. g. pemphigus, 
eczema, etc. 

6. Ulcer is the occasional result of embolic or other disturbance of the 
principal artery of the part, by which nutrition is cut off and tissue- 
death results. 

7. Bites of insects or other parasites or of noxious animals frequently 
lead to ulceration. 

8. Certain more specific forms of ulcer are described by some writers, 
apparently with more or less reason, among them being chancroid, per- 
forating ulcer of the foot, etc. Chancroid will be found described in 
Chapter XLIX. Perforating ulcer of the foot is a circumscribed cir- 
cular ulcer with thickened edges, often nearly concealed by overhanging 
skin. It may be found in any part of the sole of the foot, but is most 
common near the first joint of the great toe. The borders of the ulcer 
are usually anaesthetic. By some it is closely associated with trophic 
nerve-disturbance ; by others it is regarded as having a specific etiology 



74 SURGICAL PATHOLOGY. 

of its own. The probability, However, is that it is simply a subvariety 
of pressure-sore. 

C. Constitutional.— 1. Ulcers are frequently met with in certain con- 
stitutional conditions which are characterized by tendency to local man- 
ifestation at points of least resistance. Among these should be mentioned 
scurvy. 

2. There are ulcers of apparently distinctive trophoneurotic origin, 
of which that mentioned above as B, 8 — perforating ulcer of the foot- 
may possibly be one. These notoriously accompany certain nervous dis- 
orders of central origin, prominent among which are locomotor ataxia 
and tabetic disease of all forms. 

3. Ulcers are produced sometimes as the result of specific or selective 
action of certain drugs, among them mercury and phosphorus being the 
most prominent. These manifestations are met with in the mouth most 
commonly, and may perhaps be regarded as infections at points of least 
resistance. Nevertheless, they are commonly associated with the tend- 
ency of these drugs. 

4. There are many constitutional conditions in which vitality is so 
lowered that a special liability to ulcer — i. e. infection and production of 
ulcer at many points — is noted. It is well, however, to mention that 
the common diseases in which this tendency is most often noted are 
typhoid, diphtheria, diabetes, and syphilis. 

With this summary of the common causes of ulcer it should be again insisted 
upon that ulcers may be due to direct consequence of traumatic loss of substance 
or to the process of ulceration — i. e. as a consequence of previous infection, or as 
permitted by trophoneurotic disturbance and ischsemia. In this connection also 
ulceration should be spoken of as a process of molecular death, in which cells die 
successively and more slowly, as distinguished from gangrene, in which there is 
simultaneous death of large aggregations of cells, by which a slough or its equiv- 
alent is produced. 

Ulcers are spoken of as healthy when the process of granulation is 
proceeding with average rapidity ; indolent, when the reverse obtains ; 
sloughing, when there is actual visible tissue-death in connection with 
the ulcerative process ; phagedenic, when the gangrenous tendency is 
well marked and the process exceedingly rapid ; irritable or erethistic, 
when the surface is exquisitely sensitive ; hemorrhagic, when bleeding 
easily ; fungous or fungoid, when the granulations have risen above the . 
surface and are being manufactured at altogether too rapid a rate. 

The best examples of the indolent ulcer are seen in connection with varicose 
veins of the extremities ; of the phagedenic ulcer, in certain cases of chancroid ; 
of the irritable ulcer, in ulceration of the cornea, where the pain and photophobia 
are intense; or in fissured ulcer of the anus, where the pain and sphincter spasm 
are sometimes agonizing. 

Ulcers are described according to their shape as regular or irregular ; 
us fissured, when they extend more or less deeply and abruptly into the 
surface involved ; as fistulous, when they have a tubular arrangement ; 
as rodent, when they spare nothing in their course. 

The borders of ulcers are described as healthy, indurated, tumid, edem- 
atous, undermined, livid, inflamed, etc., these adjectives explaining them- 
selves. 

The surfaces of ulcers are described as healthy when thev have normal 



ULCER AND ULCERATION. 75 

color and appearance, inflamed, excavated, covered with sloughs, callous, 
etc. The callous ulcer is one which exhibits little change from month to 
month ; its surface is dirty, and its secretion thin and muco-purulent. 
It is usually sunk considerably below the surrounding level, while its 
border is firm and nodular. The best examples of this form are those 
accompanying varicose veins. 

In size or area ulcers may vary from the slightest local destruction 
of tissue to an area covering an entire limb or a large part of the trunk 
of the body. In depth also they vary within lesser limits, while an 
external ulcer may connect with some deep lesion by means of a tubular 
passage or sinus. It thus appears that the term ulcer may be applied to 
the result of a natural effort to repair loss of substance without intro- 
ducing the element of disease, or that it may be the consequence of local 
infection with local tissue-disaster. 

The character of the material discharged from an ulcer will vary 
much according to the category in which it belongs. The healthy, 
healing or granulating surface, often spoken of as ulcer, discharges a 
material in gross appearances much resembling pus from an acute 
abscess. In consistency it is the same, and in color and other appear- 
ances. Nevertheless, its origin is essentially distinct. This material 
represents simply the waste of reparative material sent up to the surface 
for the purpose of hurrying the process. Its fluid, like that of pus, 
comes from the serum of the blood ; its corpuscular elements, like those 
of pus, are leucocytes or wandering tissue-cells, which have been fur- 
nished in great numbers — in fact, in excess. As it comes to the surface 
— or as, rather, it is rejected from the surface, being superfluous in 
amount— it is quite likely to become contaminated with bacteria by 
contact infection, and consequently may be seen under the microscope 
to contain various micro-organisms. This contamination has been final, 
however accidental and irrelevant. This material is not pus ; has no 
infectious properties, except those which may accidentally be conveyed 
to it; represents no warfare of cells, only excess of supply or over- 
demand ; and should be spoken of as pyoid or puruloid material, and 
never confused with pus. In amount it will vary according to the 
activity of the reparative endeavor, and somewhat according to the 
amount of irritation of the surface by dressings which may be applied. 
If a granulating surface be absolutely protected from possibility of con- 
tact-infection, it will never contain micro-organisms ; while this pyoid, 
if allowed to remain too long, especially when infection is permitted, 
may decompose and become irritating, and is a material to be gently 
dislodged by a spray or an irrigating stream with each dressing, which 
dressing should be made once in twenty-four to sixty hours. 

Processes op Repair. 

An ulcer having been defined as a surface which is or ought to be 
granulating, it becomes necessary to define the granulation process and 
to show how healing is thereby achieved. Granulation-tissue is a 
name applied to a new and temporary tissue of embryonic type, which 
acts as a scaffolding or temporary structure, permitting the construction 
of more permanent tissue. It is produced entirely by the activity of 



76 SURGICAL PATHOLOGY. 

cells, which are the single and polynucleated leucocytes and the wander- 
ing cells already so often mentioned. They are frequently known as 
embryonal cells when performing this function ; sometimes as formative 
cells. They have a distinct nucleus, which stains readily, and, having 
this resemblance to epithelial cells, they are often spoken of as epithe- 
lioid cells— sometimes as fibroblasts, because they may later assume the 
dignity of connective-tissue cells. They assume a multitude of shapes. 
In a way not yet sufficiently described,* between these cells as they are 
drawn toward the point at which they are most needed, perhaps by 
chemotactic activity, there appears an intercellular substance, which later 
becomes fibrillated. As these fibres develop the remaining cells become 
entangled between them, and we have in this way a new connective 
tissue formed of cells of originally mesoblastic origin. Of such tissue 
the solid part of granulation-tissue is built. It is necessary to empha- 
size that this tissue is essentially different from the epithelium which 
it is expected will subsequently cover it. If a normal granulating sur- 
face be scanned with a magnifying glass of small magnifying power, it 
will be seen to consist of numerous minute projections, each of which is 
known as a granulation, and which consists of the tissue above described 
formed as a minute eminence around a budding capillary blood-vessel, 
from which a little projection has occurred upon the exposed surface. 
This capillary bud is the result of karyokinetic activity on the part of 
the endothelium — namely, the hypoblastic cells of which it is essentially 
composed. In each of these cells, under certain circumstances, the 
karyokinetic threads already spoken of develop and become loosely 
coiled, while the chromatin in the nucleus increases in amount and the 
nucleolus disappears. The chromatin threads become thicker, arrange 
themselves equatorially around the poles of the nucleus, and gradually 
turn so as to point toward it, while a new membrane forms around each 
separate coil, and two nuclei are thus made out of one. While this is 
going on within the nucleus the cell-protoplasm undergoes active rotary 
motion, is finally segmentated, and by the time the nucleus is divided 
is nearly ready for complete division of the cell. While nuclear division 
is usually bipolar, it may be multipolar : if a rearrangement of the pro- 
toplasm is delayed, the result becomes a multinuclear cell, known as a 
giant cell. 

The consequence of this endothelial activity is new cell-formation and the 
construction of a projection from the capillary which soon attains the dignity of 
its parent vessel, and, as connective-tissue cells form around it, soon becomes a 
granulation by itself, each granulation, being marked by a capillary loop of its 
own. Healing by granulation or the granulation process, no matter how set up 
or caused, is essentially the formation of hundreds or thousands of these tiny 
structures, a new one being formed on top of those which precede it, while those 
first formed and deeper down undergo condensation and metamorphosis of tissues, 
by which they are converted into something higher in the tissue scale. Under 
ideal conditions true granulation-building proceeds pari passu with epithelial 
reproduction around the margin of the granulating surface, so that by the time 
granulation-tissue has completely filled the defect, no matter how caused, epi- 
thelial covering has been completely constructed and the healing process thus 
completed. These two processes, however, do not necessarily keep pace with each 
other; and, should surface-repair take place relatively early, we may have a 
depressed scar ; while, on the other hand, should it not proceed rapidly enough 
or, to put it m another way, should the granulating process be too rapid we have 
such excess of granulations as shall rise considerably above the surrounding level 



ULCER AND ULCERATION. 77 

and may, under certain circumstances, become so exuberant that nutritive ma- 
terial cannot be formed rapidly enough, and those granulations farthest away 
from the centre of supply may die. Such exuberant granulation is often spoken 
of as fungoid, and constitutes that great bugbear in the eyes of the laity which is 
termed by them proud flesh. It has no further significance than that the supply 
has exceeded the demand and that the granulating process has been overdone. 
Such exuberant granulations may be cut away with scissors or knife, may be 
burned away with caustic agents or the actual cautery, or may be disposed of in 
any other manner without harm and only with benefit; in fact, it is often neces- 
sary to suppress this exuberant tendency by caustics and pressure, in order that 
the desired epithelial covering may be properly formed. 

Epithelium, being an epiblastic structure and capable of no other 
origin save from its like, can only be supplied from those regions where 
it has pre-existed. Consequently, ulcers involving the external surface 
of the body demand a lively epithelial reproduction in order that they 
may have a normal covering. Epithelial activity sometimes becomes 
retarded, and is much slower toward the termination of the healing 
process than at the beginning. The epithelial covering of a healing 
ulcer is always marked by a delicate whitish or pinkish film, which pro- 
ceeds from the periphery as well as from any little island of original 
epithelial structure left. It is notorious that after a certain amount of 
this repair the process sometimes comes to a complete halt, and the vari- 
ous expedients for stimulating and promoting it, as sponge-grafting and 
the different methods of skin-grafting, have been devised solely to atone 
for such sluggishness or inability. 

Ulcers of small size which are more or less exposed to the air in healthy indi- 
viduals, while also exposed to possibility of infection, nevertheless seem to escape 
it, owing to the defensive power of the blood-serum and the active cells. Such 
discharge as naturally comes from them, when not excessive, undergoes evapo- 
ration until a point is reached where a dry crust or scab is formed. Under this scab 
granulation proceeds up to a point where the pressure of the scab itself, presum- 
ably on the level of the surrounding parts, checks its activity, while at the same 
time epithelial reproduction goes on until it has been completed. Then the scab, 
being no longer of use, drops off or is detached by slight friction. 

Such is granulation-tissue : at first a mere trellis-work of temporary 
and delicate cell-structure, traced in a certain amount of intercellular 
homogeneous substance, into which the budding vessels project, the whole 
mounting nearer and nearer to the surface, day by day with variable 
rapidity, diminishing in this regard as the days go by, so that frequently 
the granulation process comes to an apparent halt before enough new 
tissue has been formed. While the superficial granulations preserve the 
characteristics above noted, those deeper down undergo firmer and more 
complete organization, and the delicate embryonic structures show the 
same tendency which they do in the growing embryo, by virtue of what 
Virchow has called metaplasia, to become converted into something 
higher and more dignified in the tissue scale. It is not given to these 
cells to specialize themselves to the extent permitting complete repair of 
organs of special sense. Thus, while a wound in the cornea or retina 
may be completely healed, it heals by cicatricial tissue, and not by repair 
of the special structures involved. On the other hand, tissues of more 
common connective type — fibrous, bone, cartilage, etc. — are capable of 
regeneration ; and it seems to be a part of the privilege of these new 
granulations to merge themselves into that kind of tissue necessary for 
filling the gap. Nevertheless, the most common result of granulation is 



78 



SURGICAL PATHOLOGY. 




Cicatricial deformity following burn (original). 



its metablastio conversion into fibrous tissue which has the special charac- 
teristic of contractility without elasticity. As the result soars contract; 

in consequence of which most 
FlG - 12 - disfiguring results are some- 

times the almost inevitable 
consequence of healing of 
extensive losses of substance. 
In certain instances it is pos- 
sible by constant effort to 
overcome the unpleasant ef- 
fect of this cicatricial con- 
traction. For example, after 
I extensive burn of the anterior 
part of the arm, the forearm 
will be gradually and perma- 
nently flexed upon the arm by 
virtue of contraction of the scar 
in front of the elbow, unless 
some forcible means be prac- 
tised for maintaining exten- 
sion of the arm for at least a 

part of the time. So with many other injuries and the various mechanical 

or other expedients required 

to prevent the untoward re- 
sult. Nowhere are the con- 
sequences more disfiguring or I 

serious than about the face,! 

where eyelids are drawn out I 

of shape, the contour of thel 

mouth altered, or where some- 1 

times one may see extensive I 

manifestations of this samel 

most undesirable consequence I 

(See Figs. V2 and 13.) 

As the result of healing of 

the granulating surface, v 

have what is known as al 

cicatrix or scar. This is| 

composed of fibrous tissue, 

probably more or less dis-l 

torted by virtue of its con- 
tractility, and of epithelial 

covering furnished from thel 

margin of the original ulcer, I 

constituting a thin, glistening I 

membrane, applied closely to I 

the scar-tissue beneath, with- 1 

out intervening fat or tissue I 

which permits of the play of Cicatricial deformity followingtarn : side view , ; ,„, 

the one upon the other. When case (°nsuuii)- 

this epithelial surface is abraded, it is repaired with difficulty, and a raw 




ULCER AND ULCERATION. 



79 



similar irritation of the 
Fig. 14. 



or ulcerating scar is usually a difficult thing to heal. Manifestation of 
perverted epithelial outgrowth is frequently provoked at these points by 
the action of continuous irritation. In consequence we have what is 
generally recognized as the U-ausformatkm. of a chronic ulcer, or the 
site of one, into an epithelioma, or possibly, 
connective-tissue elements, into a sar- 
coma. This is the so-called cancerous 
degeneration of previous ulcers, and is 
noted occasionally. The lesion is one 
which often requires disfiguring, or 
even mutilating operations in order to 
get rid of the malignant disease. 

The surface of a superficial scar while thus 
covered with epithelium shows a complete lack 
of all the other skin-elements. No hair grows 
upon such a surface, because the original hair- 
follicles are destroyed ; neither is it moistened 
by perspiration nor anointed by sebaceous ma- 
terial, because the secretory glands have also 
disappeared. It is a surface which often needs 
more or less protection, especially when in ex- 
posed situations. 

Treatment. — Here, as in all other 
instances, the first effort of the surgeon 
should be to remove the cause, be it what 
it may. This may be done by local, or 
may require constitutional, measures. If 
a definite local cause can be made out, its 
removal may be a slight, or may entail a 
more or less serious, surgical operation. 
Aside from this disposal of the exciting 
agent, treatment must be divided into the 
general and the local. General treatment Epitneiiomatous dege 
is scarcely called for when dealing with ulcer, necessitating ai 
healthy ulcers; but in all those instances where the constitutional condi- 
tion of the patient is below par or where there is a general poisoning or 
infection underlying the ulcer itself, prompt and energetic constitutional 
treatment should be at once instituted. In scurvy, for instance, the diet 
and hygienic surroundings of the patient should be rectified immediately. 
In syphilis no lasting nor deep impression can be made on local manifes- 
tations without general constitutional treatment. In tuberculosis and the 
other surgical infections much will be accomplished by internal medica- 
tion, by proper hygiene, as well as by local applications or operation. 
The importance of these general measures is likely to be under-esti- 
mated, and many fail to realize the advantage of combining suitable 
internal and external therapeutic measures. 

Local Treatment. — First of all should be mentioned the complete 
insistence upon repose which brings about that which we best know as 
physiological rest. . The ulcer which may never heal so long as the parts 
are constantly moved may show a prompt and kindly tendency so to do 
as soon as the part is put absolutely at rest. This may mean wearing a 
splint or restraining apparatus, or it may mean confinement in bed, 




:neration of chronic 
amputation (original). 



80 



SURGICAL PATHOLOGY. 



Fig. 15. 




Cicatricial deformity following 
specific ulcer (original). 



depending upon the locution of the ulcer. Physiological rest will be 
enforced sometimes by such measures as stretching a sphincter in order 
to temporarily paralyze it in cases of irritable rectal ulcer, where the 
principal pain is produced by the reflex spasm of its fibres. Again, the 

eye with irritable ulcer of the cornea is some- 
times kept so tightly closed by the same kind 
of spasm there that it is necessary at times 
to divide the lids, or the orbicularis muscle at 
the angle of the lids, in order to make access 
to the part. This is in a measure carrying out 
the principle of physiological rest, because it 
permits proper exposure and treatment. 

The absolutely healthy and kindly-healing 
ulcer needs no treatment except protection. 
Epithelial covering will probably keep pace 
with filling of the depression by granulations, 
and all that it is necessary to do is to prevent 
external irritation. Should there be excess of 
discharge, the simplest possible absorbent dress- 
ing, with enough of some antiseptic material to 
prevent putrefaction by contamination with 
the ordinary bacteria of the surrounding air, 
should be employed. The ulcer which is be- 
coming tardy in its repair may be stimulated 
by silver nitrate, zinc chloride, or other more 
or less caustic applications, which act as a spur to the sluggish granula- 
tions, destroying those with which it comes in contact, but stimulating 
those below to do their duty more promptly. 

The conventional applications to ulcers fall usually under two cate- 
gories — the watery solutions and the unguents. 

Of late the investigations of the laboratory have led to the employ- 
ment of numerous peptonized preparations, among which may be men- 
tioned peptonized cod-liver oil and some of the partially or predigested 
foods, such as bovinine, etc. These appear to have the power of digest- 
ing sloughs and of causing a speedy separation or disposal of everything 
which one wants to get rid of in the endeavor to secure a healthy con- 
dition of the ulcerating surface, and give in many instances most sat- 
isfactory results. When sloughs are present it is frequently an advan- 
tage to dust over them some of the preparations, like papoid, caroid, 
etc., which have the power of catalytic disposition of decomposing 
material without reference to action of bacteria. Under their use there 
seems to be a sort of solution and disposition of these dead products. 
With a foul ulcer — one from which the discharge is more or less offen- 
sive, due usually to decomposition of sloughing masses not yet sep- 
arated — the method of continuous immersion in hot water, when it can 
be carried out, is always valuable. But I have never found anything 
for this purpose equal to ordinary brewers' yeast; it may be applied on 
absorbent cotton (which should be soaked in it) and covered with oiled 
silk. Its wonderful property may perhaps be ascribed to the nuclein 
which it contains in a nascent state. At all events, it will, when fresh, 
clean off a sloughing surface better than anything I have ever used. 



ULCER AND ULCERATION. 81 

Many ulcers are surrounded with such firm, indurated borders that it 
seems impossible that any active regenerative process can arise from 
such source. Hence incisions have been practised for centuries. These 
have been made radially from the centre or have been made parallel to 
the margin of the ulcer, or sometimes the firm, dense tissues have been 
minced or chopped by a series of cross-cut stabs or incisions ; as the result 
of which renewed activity has been set up, and an impetus, oftentimes 
sufficient, has been given to the healing process. These methods, however, 
have now yielded to that just above alluded to. The comparatively 
recent ulcer in which granulation has come to a stand-still is often 
treated with the sharp spoon or curette. The result of this has been to 
provoke again a speedy renewal of granulation efforts, and treatment by 
curetting is standard and often useful. Actual cauterization of the ulcer 
with a view to such complete destruction of its covering and border as 
shall lead to their separation by the sloughing process is occasionally 
practised. This is perhaps best performed with the actual cautery. It 
lacks, however, the valuable features of the operative method to be 
described below. Modern methods have made it plain that it is often 
an absolute waste of valuable time to resort to the older expedients of 
stimulation, incising the edges, etc., and that one can accomplish by an 
operation in perhaps three weeks what ten times that length of time 
would' fail to do by older methods. The most effective method, therefore, 
in dealing with, old and chronic ulcers is to anaesthetize the patient, to 
excise the entire affected area — i. e. the surface which ought to be granu- 
lating and the firm border and tissue in its neighborhood — and then to 
cover this surface either with skin-grafts, pared off with a razor according 
to the Thiersch method, or with a strip of skin whose full thickness is 
raised, which is taken from surrounding parts by some auto- or hetero- 
plastic method. This line of treatment is so far preferable to all others 
that, except in case of refusal of the patient to submit to it, it is the 
one which must hereafter universally commend itself. It may afford 
opportunity for extensive plastic operations or for the exercise of the 
best discretion and knowledge of experienced men ; yet cases are rare in 
which it cannot be successfully carried out. These methods of skin- 
grafting have so far supplanted the older method of sponge-grafting 
that the latter is now scarcely ever practised. It may possibly 
have a sphere of usefulness in certain ulcerated cavities, but under all 
other circumstances it must take a position far below the plastic methods 
in practical value. 

Finally, ulcers of specific type — syphilitic, tubercular, leprous, 
glanderous, etc. — all need methods in which the first effort shall be not 
so much to arrange for healing as to dispose of infectious material. 
The knife, the scissors, the sharp spoon, come first into play here, the 
surgeon bearing in mind that almost all this material is more or less 
infectious, and that inoculation of his own hands is possible as the result 
of carelessness. After taking away with instruments all the granula- 
tion-tissue with its surroundings which seems to expose to danger, it 
would be well to thoroughly cauterize the part with the actual cautery, 
nitric acid, bromine, zinc chloride, or something of the kind as a mat- 
ter of insurance of the desired purpose. 

The markedly hemorrhagic ulcer, whose surface bleeds on the slight- 



82 SURGICAL PATHOLOGY. 

est contact or disturbance, is often a cancerous ulcer, though not neces- 
sarily so. This ready bleeding is usually the cause of the extreme 
fragility of the tender walls of the rapidly new-formed blood-vessels. 
In many instances it is enough thoroughly to scrape until one comes 
down upon harder or more resisting tissue. Hemorrhage may be pro- 
fuse for the moment, but it is almost invariably easily controlled. 
Caustics may then be applied or not, according to the judgment of the 
surgeon. 

Another method is to treat such a surface with the actual cautery. Another 
is to operate, even in the presence of really incurable disease, simply in order to 
check tendency to fatal hemorrhage before the natural tendency of the disease 
has expended itself. In a general way, with regard to all small ulcerating can- 
cerous surfaces, one may say that if they bleed excessively or are unduly irritable, 
it is perfectly legitimate to attack them by operative measures in spite of the im- 
possibility of effecting a cure. 

Numerous other methods of treating ulcers may be found in the older text- 
books, but they have, in whole or in part, been abandoned for the comparatively 
few already mentioned. 



CHAPTER V. 

GANGRENE. 

By Roswell Park, M. D. 



This is known also as necrosis, although by general consent this 
term is usually limited to gangrene of bone. It is known also to the 
laity as mortification, and to the older writers, especially when soft parts 
die and separate in sloughs, as sphacelus. Gangrene means death of 
tissue in visible and more or less circumscribed masses. It is to be dis- 
tinguished from ulceration because now we have to deal not with a pro- 
cess of molecular disintegration, particle by particle, but with death in 
toto and synchronously of a large perhaps innumerable number of cells. 
Gangrene is described as due to causes which may be — ■ 

A. Traumatic, including the so-called thermal causes as essentially 
mechanical injuries. Under this head would come all cases where 
injury is the primary cause, whether this injury be the crushing of a 
limb, the separation or occlusion of its main blood-vessels, the division 
of its main nerves, the crushing or pulpefying of its entire structure by 
machinery or accident, and also those so-called thermal cases which are 
due to intense heat or intense cold. To these might be added the 
chemical causes, comprising injuries by powerful caustics, alkalies, or 
acids, which are known to cause speedy death of every living tissue 
with which they come in contact. 

B. Local Causes. — These are largely connected with ischcemia, pro- 
duced in one way or another. Gangrene from oedema — itself the result 
of passive hyperemia and exudation — is not infrequent, the most com- 
mon expression of this condition being seen, perhaps, in the external 
genitals of the male. Embolism due to valvular heart disease, thrombosis 
due usually to a preceding phlebitis, but possibly to marasmic origin, 
especially met with after confinement, with disturbance in the uterine 
sinuses, shutting off the circulation by endarteritis, which thus assumes 
the form obliterans, are some of the local causes which concern the blood- 
vessels alone. In fact, the majority of cases of spontaneous gangrene 
are probably due to changes in the vessels, endarteritis being the cause 
of a condition known as atheroma of vessels, in which fungoid out- 
growths or, rather, ingrowths into the vessel-lumen, are common. Any 
one of these, if detached, may serve as an embolus. The degenerative 
excavations in the thickened walls of the blood-vessels which discharge 
more or less cholesterin and other debris, and which have in time past 
been known as atheromatous abscesses (misnomer), are frequently the 

83 



84 



SURGICAL PATHOLOGY. 



precursors of the disease under consideration. As the result of these 
changes alone, without reference to formation of emboli, vessels may 
become completely occluded, especially when slightly injured. 

Extravasation of blood is another cause connected with the blood- 
vessels, this coming usually from traumatic rupture, possibly from 
idiopathic causes. At any rate, the tension in the part may threaten 
its life because of the pressure which overcomes the circulation of blood. 
Ligation of the main trunk of an artery is sometimes followed by gan- 
grene, no matter how carefully done, collateral circulation being insuf- 
ficient to sustain the nourishment of the part. In certain fractures, 
simple as well as compound, the blood-supply of a part is rudely broken 
off by injury to a blood-vessel in such a way as to cause local or general 
death, either of a bone or of the entire limb. Flaps made for plastic 
purposes, arranged without sufficient regard to their proper blood-sup- 
ply, or so dressed after operation as to sustain undue pressure, are often 
so shut off from the heart as to die for want of blood. Finally, gan- 
grene may be the result of pressure either from splints, bandages, etc., 
or from tumors increasing in size, or possibly, as in certain pressure- 
sores, etc., from the mere weight of the body. Here, too, chemical 
agents must be mentioned, referring now to the peculiar action of certain 
foods or drugs, particularly ergot. Thus, antiseptic solutions, partic- 
ularly carbolic acid, may be made strong enough to destroy the vitality 
of certain tissues. Carbolic gangrene (Warren) is a possibility not to be 
forgotten. 

C. Constitutional Causes. — Among these are to be mentioned partic- 
ularly that symptom-complex ordinarily known as diabetes or glycosuria. 

It is notorious that this means a depraved 
condition of the system in which gangrene 
is threatened or permitted under circum- 
stances which otherwise would have little or 
no disastrous effect. Thus diabetic gangrene 
has come to be one of the recognized mani- 
festations of the general subject. That the 
trophic nerves have a more or less pro- 
nounced effect in determining gangrene in 
certain cases seems to be now quite well es- 
tablished. It is well known how quickly 
bed-sores form after injuries to the spine, 
while in certain nervous affections a mini- 
mum of friction of the skin may determine 
its death, particularly about the labia or 

scrotum. It is said that the insane, when 

^Sf^^SSm^^ir^.^ slee P l>v chloral, may develop 
™ . , „ , decubitus from pressure in a single night, 

lnere is also a well-known form of symmetrical qangrene, known some- 
times as Raynaud's disease, which is characterized by symmetry of 
lesions and absence of definite pathological changes. The so-called 
dujih mortal, or dead fingers, are expressions of trouble of this same 
character; so is a so that condition described by neurologists as erythro- 
melalgia A condition almost leading up to gangrene, but perhaps not 
absolutely terminating in such a way, has been known as local asphyxia 



Fig. 16. 




GANGRENE. 



85 



which seems to be a condition of arterial spasm with venous congestion 
and slight oedema. 

As constitutional causes also must be included the deleterious effects 
of certain drugs, particularly ergot, mercury, and phosphorus. 

D. Infectious Causes of Gangrene. — In the instances already men- 
tioned I have avoided reference to the infections micro-organisms. There 
remain to be considered special types of gangrene due to the activity of 
certain micro-organisms — among these that variety of gangrene known 
to our fathers as hospital gangrene, as well as phlegmonous erysipelas, 
malignant oedema, gangrenous emphysema, noma, ainhum, etc. 

Gangrene as the result of infectious processes is met with, for instance, in 
severe cases of phlegmonous erysipelas, where death of tissue seems to be due to 
the combined influence of the invading organisms and of mechanical agencies — 
i. e. tension produced by stasis and exudation, with such stretching of tissues or 
overcrowding them with inflammatory products as to virtually strangle them, in 
consequence of all of which they die. Gangrene of an entire hand may thus 
result, or, more commonly, the gangrene is limited in extent to the more super- 
ficial parts, so that sloughs separate. A peculiar and specific form of gangrenous 
inflammation is that also known as malignant cedema, which is due to a peculiar 
anaerobic bacillus, and which will be treated of separately under a distinct head- 
ing. Quite like it in several respects is the gangrenous emphysema of certain 
writers, known also as the fulminating form, or, as the French call it, the "gangrene 
foudroyante." More or less emphysematous condition may accompany malignant 
cedema ; yet that we do get gaseous forms of gangrene without the specific bacillus 
of malignant cedema is established. 

Hospital gangrene, so called, has been in years past the terror of mili- 
tary surgeons and camp hospitals. As a type it has almost completely 
disappeared from observation, and, in its old manifestations at least, is 
now practically never seen. 

Noma, known also as gangrenous stomatitis, cancrum oris, and gan- 
grwna oris, is a term applied to a form of tissue-necrosis affecting the 
cheeks or parts about the face of young children, occurring frequently 




Noma (Original). 



as a complication of the exanthemata. A similar condition occasionally 
involves the external genitals. From the fact that it seldom passes 



86 



SURGICAL PATHOLOGY. 



Fig. 18. 



across the middle line, it has been regarded by some as of neurotic 
origin. Naturally, bacteria are always found in the decomposing tissues ; 
but whether there as cause or as result is not yet absolutely established. 
The probability is, however, that we have to deal with a specific form of 
infection. The loss of substance is usually so great as to determine 
complete perforation of the cheek, so that the jaw-bones may be laid 
bare. The gums and alveolar processes also frequently share in the 
process, and the teeth accordingly drop out. Death of tissue is rapid, 
and septic infection may accompany it to such extent as to cause death 
of the little patient within two or three days. While theoretically most 
vigorous measures are necessary for combating it, these patients are 

often so reduced as to preclude the 
possibility of doing much, and death 
is the common termination of noma. 
Should patients recover, there is 
extensive deformity as the result of 
cicatricial contraction. 

Along the coast of Africa and in 
the West Indies there occurs among 
the negroes a peculiar gangrenous 
affection of the toes known as 
ainhum. This may assume either 
the moist or the dry type of gan- 
grene, but the result is gradual 
separation of the part, usually by 
the dry process, as if it had been 
strangulated by • a ligature. The 
disease is very slow and may ex- 
tend over ten years. The minute 
cause is as yet unknown. 

Finally, gangrene is the termi- 
nation of the infectious process in several other zymotic diseases, among 
the best illustrations being that afforded by diphtheria. The formation 
of diphtheritic ulcers in the mouth and the vulva, about the eyes and 
elsewhere, as the result of separation of sloughs, is too frequent to pass" 
unnoticed, yet at the same time does not essentially differ from the sepa- 
ration of sloughs due to any other specific cause. All these acute zymotic 
diseases, therefore, need to be regarded as among the possible causes of 
gangrene by infection of tissues. 

The symmetrical gangrene, often paroxysmal, affecting the fingers and 
toes, described by Raynaud and often called by his name, is due to vaso- 
motor spasm, and is accompanied by neuralgia and sensory disturbances, 
with coldness of the part and discoloration suggestive of impending 
gangrene. (Vide above.) 

Billroth and others have also described a spontaneous or angio-neurotie 
gangrene of the extremities, occurring during youth, in abrupt distinc- 
tion to senile gangrene, whose course is tedious and painful, and which 
will usually necessitate amputation. The cause of this condition has 
been found to be a well-marked arteriosclerosis and thrombosis, both 
in the arteries and veins. This form of gangrene occurs most often in 
the frigid zone — v. g., in Northern Russia. 




Section of noma cheek ; showing necrosis of 
tissue from bacterial infection (Miller;. 



GANG BENE. 



87 



Gross Appearances. — In a general way, tissue-death, known as 
gangrene, assumes two quite opposite types — the moist and the dry. 
In moist gangrene, aside from those general appearances which plainly 
indicate commencing putrefaction of tissues, and the loss of heat due to- 
shutting off of the blood-supply, 

one of the most characteristic Pig. 19. 

features is the formation of a so- 
called line of demarcation — i. <=., 
border whichs separates the dead 
from the living tissues. While 
this is usually plainly indicated 
by a red line which usually more 
or less abruptly separates the dis- 
colored, usually dark, dead por- 
tion from the bright-red, con- 
gested appearance of the living 
tissues, we note that this area of 
redness shades out into a more 
and more natural appearance as 
we pass upward, while below the 
line we note a surface, usually 
covered with blisters, from which 
exudes a foul-smelling altered 
serum, while the gangrenous por- 
tion usually assumesa dark, finally 
an almost black, appearance, re- 
taining only the crude outlines 
of its original shape. Along with 
this the objective evidences of 
putrefaction are unmistakable, appearances and odor being charac- 
teristic. With all there are more or less constitutional disturbance, 
and a recognizable, often a profound, condition of septic infection, 
due to the fact that along the line of demarcation absorbents are 
still active, and that the poisonous products of putrefaction are being 
absorbed into the general system. Consequently, collapse, profuse 
perspiration, septic diarrhoea, etc., are commonly noted. In gangrene 
from frost-bite the process is usually somewhat more slow than in 
the more distinctly traumatic forms. In gangrene from extravasa- 
tion of urine the separation of sloughs is often extensive, and com- 
plete sloughing of the scrotum with exposure of the testicles is a not 
infrequent result. In decubitus or bed-sore the process is still more 
slow, but always of the moist type. After a variable length of time 
there is separation of slough and a resulting large, often foul, ulcer. 

Dry — or, as it is usually known, senile — gangrene presents a very 
distinct contrast to the moist type. It is met with almost invariably in 
patients over fifty, and occurs often as the result of causes which are 
slow of action. As the result of the shrinking and corrugation of the 
tissues, along with the dryness of the same by evaporation, we have a 
peculiar appearance known as mummification, the foot, for instance — for 
the feet are usually first involved — very much resembling the foot of a 
person who has been embalmed, except that it is discolored. It is pos- 




Moist gangrene of foot (original). 



88 SURGICAL PATHOLOGY. 

sible sometimes to have a combination of moist and senile gangrene, 
especially when there has been infection by which putrefaction is per- 
mitted. "When from the outset putrefactive processes are absolutely 
prevented, the gangrene of this type is almost invariably dry. In prac- 
tically all of the cases of this character there will be found evidences 
of vascular disease, usually in the femoral artery and its branches. 
Gangrene of the foot alone is most commonly due to endarteritis, 
while gangrene of the foot and leg together are usually due to embolism 
or thrombosis. 

Signs and Symptoms. — Aside from those already mentioned, which 
are recognizable at a glance, there is but little more to say. The ap- 
pearance and the odor of a part will quickly indicate impending or actual 
traumatic gangrene. The pallor, the coldness, and the dryness of senile 
gangrene are also characteristic. In the latter form, at least up to a 
certain point, constitutional symptoms are not indicative nor essentially 
of septic type. Just so soon, however, as a process of spontaneous sepa- 
ration begins putrefaction is inevitable and sepsis unavoidable. In moist 
gangrene there is seldom acute pain. This is one of the predominating 
subjective features of the senile forms, at least in many instances. Hem- 
orrhages occur, sometimes terminating fatally, in the moist forms when 
large vessels are eroded. This is particularly true of the phagedenic or 
hospital form. A recognition of their possibility may enable us to avoid 
sudden death from this source. 

Treatment. — We shall speak first of treatment of threatening gan- 
grene, which, so far as it may be possible, should impel us to attack and 
remove the cause. Threatening bed-sores may be avoided bv equalizing 
surface pressure, and this best with the water-bed ; by protecting the 
skin or by stimulating and toughening it with alcoholic and astringent 
lotions ; by frequent changes of position ; by attention to the heart, 
which should be stimulated to a point that may make it capable of for- 
cing or distributing blood equably over the entire body. So, too, with 
limbs which are enveloped in dressings or splints : it is always well to 
leave exposed the tips of the toes or fingers, at least when practicable, 
in order that discoloration of the same may be quickly' recognized 
and the threatening disasters averted. Local gangrene as the result 
of pressure by tumors, aneurisms, etc. cannot alwavs be averted, 
though one realize its imminence. These are cases where one needs 
must sit hopelessly and helplessly by and see that occur which he can- 
not obviate. 

For gangrene which has actually occurred there is but one relief, and 
that is the removal of the dead and dying tissue. The method and loca- 
tion of the operation must be determined somewhat, however, by the 
general character of the cause. For a case of acute traumatic gangrene 
amputation at the nearest point of election above the injury will often 
suffice. In case of gangrene from frost-bite the tissues in the neighbor- 
hood of the line of demarcation are often so affected or their vitality so 
compromised that to simply separate the tissues along the lines at which 
nature is endeavoring to remove them is not enough, and to go an inch 
or so above this line is simply to operate in tissues which bleed readily 
and heal badly. Consequently, here it is often good judgment to select 
a suitable point at some distance above. But it is especially in the forms 



GANGRENE. 89 

of diabetic ancT senile gangrene that surgeons have now laid down the 
rule that if amputation be done at all, it must be high. If one have senile 
gangrene of the toe, for instance, as the result of disease of the vessels, 
he may be sure that it will be wise to amputate at least above the ankle ; 
whereas if any greater portion of the foot be threatened, it will be emi- 
nently judicious to amputate above the knee, if at all. I have repeatedly 
under these circumstances found the tibial arteries so brittle as to snap 
under a ligature, and even the femorals so disorganized as to require 
handling and ligating with the greatest caution. These high amputations 
are therefore necessitated by the condition of the vessel-walls ; all of 
which must needs be explained to many patients before they can appre- 
ciate the reasons for such high operations or consent to them. While 
amputation for traumatic and acute cases is, in the majority of instances, 
if not too long delayed, successful in saving life, in the senile, and par- 
ticularly in the diabetic forms, it is in the majority of cases a disappoint- 
ment ; and my advice to all, especially to young men who are chary 
about assuming responsibility, is to have these matters definitely under- 
stood and the situation thoroughly canvassed before consenting even to 
make such an operation, urgently as it may seem indicated. 



PART II. 
SURGICAL DISEASES. 



CHAPTEE VI. 

ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 

By Roswell Park, M. D. 



One of the greatest advances made in recent pathology has been the 
establishment of the fact that a great many of the morbid conditions 
from which the human race suffer are those due to causes arising 
entirely from within their own systems and in consequence of deficien- 
cies of elimination or of perverted physiological processes which, in 
large degree, are themselves the result of errors and indiscretions in diet, 
in manner of life, in habits, etc. That these general facts have been 
recognized for centuries is perhaps a credit to the powers of observation, 
of practitioners of past generations. Exact knowledge, however, has 
come only with exact laboratory methods of research and most pains- 
taking study of the secretions and excretions, both under normal and 
morbid conditions. The subject of auto-intoxication has been too com- 
monly relegated to the domain of internal medicine, and has been sup- 
posed to be one in which the surgeon, as such, need take only passing 
interest. 

The alkaloids are by no means the only poisonous products which 
the human body may produce and retain. That most important excre- 
mentitious material of all — i. e. carbonic dioxide — could not be retained 
in the organism for more than a few moments without death as the in- 
evitable consequence. The various soluble ferments elaborated by certain 
glands may exert deleterious influence, both local and general ; and in 
the saliva are also found products which are not ferments. The biliary 
acids also, if they do not find free escape, may produce fatal poisoning. 
So also leucin, tyrosin, and all of the excrementitious products which 
arise from insufficient liver-activity, are capable of producing forms of 
intoxication — such, for example, as eclampsia, etc. By no means all of 
the alkaloids produced within the body are poisonous. Some of them 
are met with in the normal tissues, and they are, perhaps, only one of 
the many results of the disassimilation of animal cells. Nor are all 
these poisions of bacterial origin, although many are only formed in the 
presence of microbes. 

From these constantly-menacing sources of intoxication man escapes 
by virtue of his intestinal, cutaneous, pulmonary, and renal emunctories. 
For instance, the usefulness of the perspiration is shown by the odor 

91 



92 SURGICAL DISEASES. 

which it assumes under the influence of certain disorders. Amongst 
hypochondriacs and the inactive, fatty acids are eliminated abundantly 
by the skin. Hence the odors of hospital wards, asylums, prisons, etc. 
So, too, in the case of many who suffer from deep-seated, indolent 
ulcers, the odor of the skin is suggestive of the presence of pus. During 
twenty-four hours there are eliminated from the lungs 1100 grams of 
carbonic dioxide, water, etc., which sometimes contain ammonia and 
various volatile fatty acids ; all of which will explain fcetor of breath 
when it is the result of incomplete nutrition and destruction of food. 
Of all the organs of elimination, the most important is the kidney, which 
can never be charged with reabsorbing a part of its own products, as 
does the intestine. The kidneys eliminate fluids and solids, not gases. 
The most important of the toxic principles contained in the urine are — 

1. Urea, which ordinarily plays a most important and useful role in 
the economy, since it possesses the property of forcing the renal barrier 
and removing along with itself both the water in which it is dissolved 
and other toxic matters. Urea is toxic, but only in the sense that any 
other substance, even water, may be so — i. e. it is toxic only in relatively 
enormous doses, much less so than sugar, and no more so than the most 
inoffensive salts. This is contrary to generally received views, but is 
experimentally clearly established by the researches of Bouchard. 

2. A narcotic substance, and 

3. A sialogogue substance, whose composition is unknown. 

4. 5. Two substances having the property of causing convulsions, one 
having the power of contracting the pupils. Composition of both un- 
known. 

6. A substance which produces heat by diminishing heat-production 
— possibly a coloring matter. 

' 7. Potassium salts, which are really convulsing agencies, and are the 
most toxic perhaps of any of the poisons contained in the urine. The 
chloride of potassium, for instance, is toxic at 18 grams for every kilo 
of animal. 

Salivation and myosis, as well as diarrhoea, are often noticed in so-called 
urwmia. In that form known as hepatic uraemia, when the liver no longer forms 
urea, the kidneys scarcely act. In other words, if urea be no longer present in 
the body, the kidneys are deprived of their principal stimulation to physiological 
activity. Consequently, urea, for so long a time the bugbear of physicians, is 
shown to be most dangerous when absent. When urea is deficient it is most wise 
to resort to withdrawal of large quantities of blood-serum or of water in which the 
other toxic substances are dissolved. This is best done by venesection, whose value 
in so-called uraemia past experience amply corroborates! When kidney activity 
ceases intoxication is most likely to be produced by potassium salts. 

Correct performance of hepatic function is also most necessary in 
order that surgical cases may progress without disturbance. Bile 
escapes direct absorption by the blood, but not all contact with it, since 
in the intestine it is in contact with mesenteric capillaries, but must 
pass again through the liver, which shall take it up anew and pour it 
once more into the intestine. 

Bile in the blood is always dangerous, although its toxicity is relatively much 
smaller than has been generally supposed. Of all the bile thrown out into the 
duodenum, we are only able to account for about one-half. Its coloring matter 
and biliary salts are metamorphosed. Yet in certain morbid conditions bile as 
such, may be reabsorbed in the liver along the margin of the hepatic cells 'in 



ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 93 

these cases, if the kidneys remain permeable, auto-intoxication is simply threat- 
ened; if they have ceased to be permeable, actual auto-intoxication is the result. 

Putrefaction of intestinal contents affords another source of auto- 
intoxication. This comes both from imperfect metamorphosis of food 
and from bacterial infection. Here the conditions are most favorable. 
Nitrogenous substances become peptonized, and peptones form the best 
culture-media for microbes. Water is present in sufficient quantities, 
and a constant temperature of 37° C. is maintained. The digestive tube 
is always open, and invaded at frequent intervals. By such mechanism are 
formed those products whose effects are revealed in the so-called putrid 
fever of Gaspard. Brieger has shown that alkaloids are developed 
during the act of peptonization. Fecal matter contains also excretin, 
whose toxicity has been amply proven, and several other alkaloidal sub- 
stances, soluble in various media, varying in toxicity. The potassium 
and ammonium salts contribute largely to the toxicity of faeces ; bile also, 
but in lesser degree. It has been shown that the aqueous extract of 
putrid matter is very toxic, but that of fecal matter is much more so. 

The most serious features of the various conditions grouped in time 
past under the heading Bright's disease are their so-called urmmic fea- 
tures. These happen at the period when retention of toxic products is 
peculiarly harmful. So long as the urine be ample in amount and of 
high enough density — i. e. containing enough toxic materials in solution 
— there is no danger of intoxication. But when it no longer eliminates 
in twenty-four hours what it ought to, then we see the chronic and par- 
oxysmal nervous accidents, the oedemas, fluctuations of temperature, etc., 
which are properly considered so serious. Oliguria with urine of increas- 
ing density and general oedema of the tissues may be noticed, although 
the other secretions continue natural and the tongue be moist. So long 
as the normal amount of solids is eliminated, this form of " uraemia " may 
be due to mere accumulation of water, and may not be serious. Ordi- 
narily, urannic patients are those whose urine has lost its toxicity. Usually 
on the day in which so-called ursemic accidents happen the urine quite 
ceases to be toxic and is scarcely more so than distilled water. Urea 
alone is not to be held guilty for this condition. In order to kill a man 
with urea it would require the quantity which he makes in sixteen days. 
Nevertheless, it may become harmful after undergoing transformation 
into ammonium carbonate or other substances. 

Among the most poisonous substances in the urine are the extractive 
and coloring materials. Normal urine loses one-half of its toxicity by 
decoloration ; bile acts in the same way. Urea alone represents about 
one-eighth of the total toxicity of urine. Ammonia is toxic, but present 
in small amounts. The coloring matters of the urine cause two-thirds of 
its toxicity, the remainder of which is to be ascribed to its mineral salts, 
which it contains in the following proportion : A litre of urine ordinarily 
contains 44 grams of solid matter, of which 32 are organic, 12 mineral. 
Of the latter, potassium salts constitute 3 grams, sodium salts 7.50, and 
other earthy salts constitute the remainder. 

In these conditions physicians have, in time past, relied largely upon purga- 
tives, hoping thereby to remove urea from the blood. But intestinal elimination 
has no elective affinity for it, and removes it only in its normal proportion with the 
balance of the blood. Purgatives, however, help, first, by dehydrating the tissues 



94 SURGICAL DISEASES. 

— i. e. removing water with toxic material in solution. But they should be followed 
by restoring to the tissues pure water. By bleeding more extractives are removed 
than by any other channel, except by the kidneys. A bleeding of 32 grams removes 
from the body as much toxic matter as would 280 grams of a liquid diarrhoea or 
100 litres of perspiration. This much may be removed by two leeches. It is espe- 
cially in the subacute nephritis of scarlatina, etc. that bleeding finds its greatest indi- 
cation. If the kidneys be chronically diseased, the utility of bleeding is doubtful, 
for we cannot continue it incessantly. Between the arterial capillaries of the bowels, 
however, and the liver is found a mass of blood accumulated in the portal vessels. 
This may now be regarded as a reserve which can be thrown into the general cir- 
culation when needed, in order that thereby we may augment arterial tension and 
so increase kidney function. Cold injections into the bowels will often accomplish 
this, and serious anuria often disappears after their use. It is reasonable now, also, 
to make deliberate use of urea by subcutaneous administration as the most power- 
ful diuretic known, surface friction, caffeine, digitalis, etc. being far behind it in 
efficiency. In that particular form of intoxication noted in the eclampsia of puer- 
peral patients inhalations of chloroform are most valuable. Potassium salts should, 
under these circumstances, never be employed. We may also take advantage of 
the fact that an exposure of urine in compressed air will diminish its toxicity, on 
account of contact with the oxygen, as well as of the fact that the most toxic bac- 
teria are those which grow without oxgyen. Consequently, by causing these 
patients to inhale this gas we may in large measure overcome this kind of auto- 
intoxication. 

The value of a thoroughly active liver is also not appreciated to the 
full extent by most surgeons. The blood of the portal vein is so much 
more toxic than that of the hepatic vein that it is most evident that the 
function of the liver is, in large measure, to purify and remove from 
the blood that comes from the intestines no small amount of highly 
toxic material. This has been called by Flint and others the depura- 
tive action of the liver. 

That facts above stated or others related thereto have not been 
entirely lost sight of by surgeons in time past is shown by such expres- 
sions as septic enteritis, enter asepsis, etc. which are used by various writers. 
In previous writings I have made a separate and distinct topic of so- 
called intestinal toxwinia, which here I have preferred to introduce as 
simply one of the many possible auto-intoxications. To be sure, it is a 
condition not always permitting of exact definition, nor, still less, can 
the exact toxic agency be certainly indicated in a given case. Neverthe- 
less, it has been made plainer and plainer within the past few years that 
there is perhaps no condition which so predisposes to saprcemia, septicemia, 
or even pycemia, as this vague condition of intestinal toxsemia, which, 
nevertheless, is so often present, I have long maintained that many 
surgical patients present forms of blood-poisoning in which the poison 
has not proceeded from the wound, and for which the surgeon is not 
responsible, except in so far as he may have neglected to avail himself 
of certain precautions based on facts which this chapter purports to 
teach. 

The practice of preparing patients for operation by a course of purgatives 
emetics, etc., which has prevailed at many times in the past, is based upon the 
crude recognition of certain principles which it is desired here to make much 
clearer. Some one, if not each, of the general symptoms included under the name 
enterosepsis, stercoraemia, copraimia, or whatever one may choose to call it is cer- 
tainly due to the activity of the colon bacillus, which seems to be made more"" viru- 
lent by certain conditions of diet or retained fecal excretions, and to sucn an extent 
that it now wanders widely from its normal habitat and may be found in distant 
parts of the body. Enterosepsis may be mistaken for surgical fever, and is to be dis- 



ON AUTO-INFECTION, ESPECIALLY IN SURGICAL PATIENTS. 95 

tinguished from it, perhaps, only by the careful study of the excretions of a given 
case and establishing the fact that they are free, and that consequently pyrexia, 
etc. cannot be due to diminished elimination. Aside from the migrations of the 
colon bacillus, it is also possible for such ;i degree of auto-intoxication to occur 
that infection by other organisms is permitted, as it would not otherwise be; and 
thus that which is to-day stercorsemia may become in a day or two a genuine sep- 
ticaemia, vital resistance being lowered to the extent of permitting local infection 
that could otherwise not have occurred. The various conditions are clinically so 
often merged together that it is difficult or impossible to separate and identify them. 
Nevertheless, the fact should be taught as plainly as our language may permit that 
enterosepsis differs from saprsemia, to be considered shortly, in that in the one 
instance the putrefying material is contained within a normal cavity, whereas in 
saprsemia it is contained within an abnormal cavity, in either case corresponding 
to a septic suppository, varying, however, in the place of insertion, varying also in 
the nature of the surrounding tissues, which in the latter case are much more 
capable of absorption and of becoming infected than in the former. 

A determination of indol and indican is often of the greatest value, both in 
determining the extent of infection and the presence of pus. Indol is set free 
under the following circumstances: a. Suppuration in a closed cavity, b. Con- 
tinued suppuration in a cavity with an outlet, c. Ulceration or necrosis of tissue. 
The degree of indicanuria will depend on the length of time during which pus has 
been present, the possibility of absorption from the tissues surrounding it, and 
their extent. When pus is fully formed in a serous sac the indican-reaction be- 
comes intense in proportion to the length of time during which pus has been 
present. This is particularly true in the empyemas of childhood. In continued 
suppuration with a free outlet the production of indol will be great ; but the amount 
finally eliminated will depend upon the character of the surrounding tissue. When 
solid tissue, like bone, becomes affected the elimination of indol is most intense. 
Rapid biogenic degeneration of tissue causes an increased amount of indol to be 
deposited in the liver, and it is possible at post-mortem, by simple extraction 
with absolute alcohol, to take from the liver this excess deposit in the shape of its 
oxidation-product, indigo blue. Lardaceous degeneration is characterized by 
marked and persistent elimination of indol, which seems to be a product of 
tyrosin. It occurs most often in the liver, in which indol is notably deposited. 
Its primary factor is deposited by the blood, in which later indol circulates and is 
oxidized. Lardaceous material gives a red or blue color with oxidizing agents, 
which latter yield with indol an indigo red or blue. 

The practical outcome of such a chapter as this is, then, to insist as 
strongly as possible on the preparation of patients, whenever this is 
feasible, for an ordeal which comprises the combined effect of anaesthesia 
and consequent disturbance of secretion and elimination, with loss of 
blood and of strength, and subsequent confinement in bed, with, more- 
over, all that this entails in further impairment of activities of important 
organs. It is not always possible, practically rarely so in emergency 
cases, to adopt these precautions ; in which cases they must be atoned 
for, so ffir as possible, by extra attention in the same directions after the 
emergency is passed or has been met. In the former case, however, the 
functions of the skin, the kidneys, and the abdominal viscera must be 
regulated — the first by hot-air baths ; the second by this same measure 
in conjunction with copious draughts of pure water, the correction of 
hyperacidity of the urine, and the administration of whatever drugs 
may be of benefit as diuretics, etc. ; and the third by a course, perhaps 
covering several days, of gentle or active purgation, by which the ali- 
mentary canal shall be entirely emptied of all that may serve to act as 
a source of poisoning. In addition to this, in certain cases careful mas- 
sage will dislodge from the muscles and other tissues material which 
they ought not to retain, and which shall be washed away, as it were, by 



96 SURGICAL DISEASES. 

the extra amount of fluid which this preparation necessitates. In addi- 
tion, also, the activity of the heart should be stimulated, perhaps by- 
digitalis, but preferably by that best of all tonics, strychnia, which is to 
be administered hypodermically in average doses of a thirtieth or twenty- 
fifth of a grain, morning and night. When these precautions are taken 
patients will successfully pass through most trying ordeals without any- 
thing which may give rise to alarm. When they are not possible, the 
risk of operating, even in a small way, is materially enhanced. So, too, 
after operations when these precautions have not been taken it is neces- 
sary to give most careful pains to atoning for their lack by such active 
purgation as a now reduced patient may bear — by hot-air baths, if feas- 
ible, and by the administration of such intestinal antiseptics as charcoal, 
naphthaline, corrosive sublimate, bismuth salicylate, salol, etc., for the 
purpose of reducing to the lowest possible minimum the opportunity for 
formation of poisons which shall disturb the proper repair of injury. 



CHAPTER VII. 

THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 

By Roswell Park, M. D. 



Surgical Fever, known also as Traumatic Fever, or 
Aseptic Wound-fever. 

In times past, when operations were never done aseptically and when 
ideal wound-healing was unknown, the surgical fevers were all grouped 
together, and a certain amount of febrile disturbance was looked for 
after any injury. But with the introduction of antiseptic methods and 
with healing of wounds by primary union, with absence of all septic 
phenomena, and at present when the careful use of the clinical ther- 
mometer is common, it is noted that there is, nevertheless, a certain 
rise of temperature more or less quickly after an operation or recep- 
tion of a wound, with fever of mild grade persisting for several hours 
or two or three days, and with certain other accompaniments which are 
usually noted along with it. This phenomenon has been carefully 
studied, and so completely separated from the septic fevers as to have 
deserved a distinct recognition under the names above given, of which 
the most common in this country is surgical fever. 

So long as this fever be free from indications of septic character it is 
without significance and needs only symptomatic treatment. It begins 
usually within the first twenty-four or thirty-six hours, after which tem- 
perature may rise progressively or with a morning remission to a 
height of 102°, or possibly 103° F. In children we are more likely to 
get extremes in this regard than in healthy adults. It will be followed 
by some disturbance of alimentary function, glazing or drying of the 
tongue, deficiency in urinary secretion, and will nearly always subside 
spontaneously — invariably so if cathartics, diuretics, cool sponge-baths, 
etc. be properly resorted to. It is usually due to the retention of blood- 
clot, ligatures, etc., or tissues which have been ligated and whose stumps 
remain ; in all of which instances there is some foreign material to be 
removed. This means unusual phagocytic activity, perhaps temporary 
leucocytosis, with active metamorphosis of clot and other material ; of 
all of which the elevated temperature is an accompaniment and expres- 
sion. It is not unlikely that the antiseptic materials sometimes used 
have also to do with this pyrexia. 

Iodoform and carbolic acid are among materials in common use which are 
known to be irritating and capable of producing toxic symptoms. Often after the 
use of the latter the urine will be discolored and will furnish the clue to the fever. 
In young children particularly, and not infrequently in adults, mental disturbance, 
even to the point of active delirium, may characterize the case. This is not always 
to be explained by cerebral ansemia due to loss of blood during the operation or 
accident, but is undoubtedly in certain instances due to drug-toxsemia, or in other 
cases to intoxication from materials furnished by the altered tissues. 

7 97 



98 SURGICAL DISEASES. 

Surgical fever of strict type may merge into a more or less continuous 
fever as the result of intestinal toxaemia permitted by failure to thoroughly 
evacuate the bowels, and this intestinal toxamiia may be a predisposing 
cause of genuine septic infection. Consequently, a surgical fever which 
does not disappear within two days is to be viewed with suspicion, espe- 
cially if it do not subside after the administration of cathartics. 

Some of these surgical fevers are accompanied by eruptions, a number of which 
may be due to drugs, but some of which at least are due to intrinsic poisons. 
Thus, carbolic acid and iodoform give rise occasionally to erythematous eruptions, 
and the concomitant administration of drugs like potassium iodide, quinine, anti- 
pyrine, and copaiba may produce urticarial or other manifestations. Again, it is 
known that certain toxines — produced, e. g., by the bacillus pyocyaneus — are capa- 
ble of causing dilatation of the superficial vessels and various flushes or eruptions. 
To one of these, which dilates the capillaries, Bouchard has given the name of 
eetasine. Consequently, it by no means follows that every eruption or rash follow- 
ing operations or injuries is of a specific character. On the other hand, it seems 
to be established by numerous observers — among whom Paget is perhaps the most 
prominent — that surgical patients, particularly the young, are notoriously liable to 
infection by scarlatina ; and in the experience of Thomas Smith, of 43 children 
whom he cut for stone 10 had scarlet fever. Consequently, in spite of the fact 
that a certain number of cases of eruption may have been mistaken for scarlet 
fever, it is undoubtedly true that in surgical and puerperal cases patients are more 
than usually liable to this invasion. 

The whole subject of surgical fever may, then, be epitomized as con- 
sisting of elevation of temperature and certain accompanving disturb- 
ances, which appear to be essentially due to the results of tissue-metab- 
olism, including also metabolism of blood-clot, ligatures, etc. It is 
not a necessary nor conspicuous accompaniment of all surgical cases, and 
in some individuals, even after grave operations, will scarcely be noted. 
It is more likely to be extreme in children than in adults, other things 
being equal. As the result of excessive loss of blood it may be post- 
poned. It may be complicated, and more particularly prolonged, by 
any one of the auto-infections, particularly that already spoken of in the 
preceding chapter as intestinal toxaemia, as the result of which septic infec- 
tion may ensue, and that which was at first a legitimate surgical fever 
may thus become merged into one of the septic conditions next to be con- 
sidered. In the absence of auto-infection, and with kindly and sympto- 
matic treatment, surgical fever should quickly subside until it becomes 
indistinguishable, and this usually by the end of the second or third day. 

Proceeding, then, in the order of pathological complexities, the next 
of the surgical infectious fevers to be considered is Sapraemia. 

Sapr^mia. 

It is my purpose to use the term saprsemia here as indicating a con- 
dition which I often liken to an intoxication produced by a supposititious 
septic suppository, although the case is by no means imaginary in which 
this condition occurs. The term was first used bv Duncan, and was 
laigely confined, at least at first, to puerperal cases. This is its own 
justification, because some of the most ideal cases of saprsemia are 
those of puerperal origin. 

In each of the three conditions comprised under the general term of 
septic infection it is not now a question of particular organisms but of 
intoxication by products which are more or less common to at least 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 99 

several of them. In a general way, they are, for the most part, due to 
the activity of the orr/mumm already grouped an pyogenic. Those which 
produce pus arc easily capable of causing septic infection. In addition 
to these, it is probable that certain of the saprophytes or ordinary putre- 
factive organisms may produce the same effect. For purposes of minute 
study it is of interest to isolate and, so far as possible, determine the 
exact action of, each organism. For present purposes, however, it is 
neither necessary nor, perhaps, wise. 

In sapraemia the symptoms begin promptly, depend for their inten- 
sity upon the dosage of poison, and recede quickly as soon as the source 
of poisoning is removed or its activity antidoted. Two illustrations 
of the possible causes of saprsemia will, perhaps, best illustrate its 
pathology. Take, first, that physiological operation of nature's own 
performance — namely, the act of delivery of the full-term foetus. At 
the completion of this operation there is left a fresh, bleeding wound of 
large area which is more or less exposed to putrefactive agencies. This 
is reduced with the contraction of the uterine walls to a comparatively 
small cavity containing more or less freshly-coagulated blood. So long 
as this clot does not putrefy it is disintegrated inoffensively, to be dis- 
charged, at least for the most part, with the lochia?. Let, however, 
germs of putrefaction enter, either during the act of labor or afterward, 
and linger, and putrefactive processes are set up in the clot with the 
prompt production of certain toxines and ptomaines. We have here a 
septic suppository with conditions most favorable for absorption by the 
containing tissues. How quickly the poisoning may show itself, and 
how quickly subside after removal of the putrefying clot, daily experi- 
ence may tell. 

Saprcemia, then, is intoxication produced by absorption of the remits 
of putrefaction of a contained material within a more or less shut contain- 
ing cavity whose walls are capable of absorption of noxious products as 
they form. So long as putrefaction be essentially limited to the contained 
mass, and do not spread to and involve the containing or surrounding 
tissues, the case is one of sapraemia. So soon as the process spreads from 
the containing tissues the case merges from one of saprcemia into one of 
septicemia. That this may occur in any case without prompt inter- 
vention will be readily understood. Patients may sometimes die of 
saprsemia, though rarely, and in such case ordinarily as the result of 
gross neglect. Once the septicsemic process be begun, however, its 
spread cannot be with certainty checked, and that case which to-day is 
saprsemic and redeemable may, to-morrow, become septicsemic and prac- 
tically lost. 

The symptoms of saprsemia are not essentially different from those 
common to septic infection, save that ordinarily they are, at least at first, 
milder. There are flushing of the face, dry tongue, mental disturbance 
often, a considerable degree of pyrexia, while usually the whole train of 
symptoms is ushered in by a chill which may have been preceded only 
by slight malaise. These are usually followed by nausea and vomiting, 
with headache, and often, later, by diarrhoea or active purging. Should 
a case go on so far, delirium may occur, possibly even fatal coma. On 
post-mortem examination of a fatal case there would be few changes 



100 SURGICAL DISEASES, 

revealed : alterations in the blood, a failure to coagulate, some softening 
of the spleen and liver would probably be the only notable changes. 

Treatment. — For a condition so easily recognized treatment should 
be prompt, and will then be almost always effective. It is all summed 
up in the urgent advice to remove the cause, although this may not 
always be easy of performance. In the first case supposed — i. e. one of 
puerperal saprcemia — the treatment would be to empty the uterus, to give 
vigorous antiseptic douches, to irrigate as often as necessary, to prevent 
offensive odor to the discharge, and to combat the general signs of poi- 
soning by plainly indicated measures. Heart-depression should be 
overcome by the use of diffusible stimulants and by hypodermic injec- 
tions of strychnia in doses of -^ grain or more. The bowels should be 
promptly unloaded by a mercurial, followed by a saline cathartic. Sup- 
pression of urine may be treated by venesection and by hot-air baths or 
sweats ; diuretics should also be prescribed, and fluids should be admin- 
istered copiously. If the patient be very restless, an opiate should be 
promptly given ; if delirious, necessary restraint should be resorted to. 

Essentially the same measures should be carried out in a surgical 
wound, or in case of compound fracture, or any injury where retained 
material may be undergoing changes already alluded to. General meas- 
ures should be the same. Our forefathers were certainly wise in advis- 
ing the use of purgatives in these cases, for nature often sets us the 
example in the shape of watery and most fetid evacuations, showing 
that there is much retained whose evacuation should be hastened. 



Septicemia. 

According to the views thus enunciated, the difference between sa- 
prsemia and septicaemia is not one of character so much as of location. 
In septicemia the putrefactive action is no longer confined to material 
enclosed by, yet not of, the tissues themselves, but has spread from this to 
the surrounding living cells, which are now being attacked by bacterial 
enemies ; in other words, we deal now with infection of living tissues 
rather than with mere intoxication. This is now a progressive invasion 
of tissues by continuity, with a constantly proceeding systemic intoxi- 
cation by poisons produced ever in larger doses. So rapid mav this 
action be — as may be seen in malignant diphtheria, for instance — that 
the individual speedily succumbs before abundant evidences of abscess 
or local gangrene appear. On the other hand, providing that the toxic 
action be less pronounced or the patient's vitality more enduring — i. e. 
his tissues more resistant — abscess, phlegmon, or local gangrene may 
result, the destruction of tissue being limited to the environs of the 
parts first involved. 

While septicemia, then, may be a direct continuance of an original 
saprsemia, it is not intended to intimate that it may not originate de 
novo ; that is, many cases may begin as a pronounced septicaemia from a 
local infection. This is the case, for instance, with the majority of dis- 
secting wounds, etc. 

Symptoms. — In septicaemia we have a period of incubation, usually 
two or three days at least, often longer. If this follow an operation, the 
mild fever which would indicate the slumbering fire is usually regarded 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 101 

as merely surgical fever. But when, instead of subsiding, this rises and 
is followed by prostration with alimentary disturbance, loss of appetite, 
headache, etc., quickly followed by those general symptoms which we 
speak of as typhoidal, the alarm is sounded and should be quickly heeded. 
Usually, but not always, there is a preliminary or premonitory chill, after 
which prostration will be much more marked than before. The severity 
of the general symptoms can in no degree be foretold from the size, loca- 
tion, or character of a wound. The character of the fever is essentially 
continued, usually with morning remissions. Gussenbauer has called 
attention to a class of cases in which subnormal temperature is caused 
by the absorption of ammonia compounds. To these he has given the 
name ammonkemia. This condition may be seen oftenest in connection 
with gangrenous hernia, and has even been mistaken for shock (Warren). 

In septicaemia proceeding from infection of a visible portion of the 
body there are usually seen evidences of lymphangitis and perilymphan- 
gitis — of course of septic character. These will be evidenced by tender 
and purplish lines, extending subcutaneously along the course of the 
known lymphatics or in connection with the more prominent subcutane- 
ous veins. The lymph-nodes, into which these visible vessels as well as 
the deeper ones empty, become quickly enlarged and tender ; the whole 
lymphatic system participates ; the spleen in aggravated cases becomes 
notably enlarged, and even the bone-marrow more or less involved. 
Diarrhoea is commonly an early but controllable symptom. A heema- 
togenous icterus of mild degree is another frequent accompaniment. The 
conjunctiva becomes plainly discolored, and the skin slightly so. Should 
the blood be examined, marked leucocytosis will be noted, and should 
cultures be made from it, in many instances at least the organisms at 
fault can be detected and recovered from it. The vigor of the heart- 
muscle is seriously impaired ; the pulse becomes rapid and weak. In 
scarcely any form of septic infection is this more prominent than in 
diphtheria ; and microscopic examination shows the rapid disintegration 
of the cells of the heart-muscle, as well as those of other parts of the 
body, even to the almost complete molecular disintegration of the nuclei. 
Erythematoid, pustular, even hemorrhagic eruptions are met with upon 
the skin, some of which are probably to be explained by thrombosis of the 
dermal capillaries. Certain complications are not infrequent, among 
which inflammations of the pericardium and endocardium — e. g. ulcera- 
tive endocarditis — are frequent. As the case becomes aggravated tem- 
perature rises irregularly ; the hot, dry skin becomes cold and clammy ; 
prostration and indifference more marked ; diarrhoea more colliquative ; 
icterus more pronounced ; urine more reduced in quantity or suppressed ; 
and these symptoms are succeeded by indifference, mental apathy, stupor 
or delirium, and finally death, patients being comatose and collapsed. 

While these are the general indications of septicaemia, the wound or 
site of injury has undergone changes which are also characteristic. They 
comprise, first, the cedema and redness of wound-margins, which may be 
seen even in saprsemia, followed by increasing tumefaction, escape of 
foul-smelling discharge, and finally by sloughing and gangrene of the 
parts involved. On microscopic examination the capillaries are filled 
with infective thrombi and vessel-walls infiltrated with micro-organisms, 
which abound also in the lymph-spaces. Bacterial infection can be 



102 SURGICAL DISEASES. 

traced in microscopic sections from the infected area, from the point in 
the neighborhood of the wound where microbes infest the tissues, to 
points remote from it, where they are sparsely found, if at all. The 
same evidences of infection may be traced along the lymphatic vessels, 
and often the veins. 

The post-mortem evidences of septicaemia are plainly indicative 
on first sight : the blood is of a consistency like tar, does not coagulate ; 
evidences of putrefaction are plain to sight and smell; the serous 
membranes, particularly the pia mater, are often extravasated ; the mus- 
cles are discolored and of a darker hue than natural ; oedema of the lung 
is frequent ; the intestines reveal a gastro-intestinal catarrh, the duode- 
num and rectum particularly showing punctate hemorrhages ; the spleen 
is darkened, enlarged, and very much softened ; the liver shows similar 
signs, less marked, and at times an emphysematous condition due to 
putrefactive gases. Cultures can be made from all the fluids and tissues 
of organs thus affected. It is also of the greatest importance to empha- 
size that such material is powerful!)/, often fatally, infectious; and some 
of the worst forms of dissecting wounds and most rapid instances of 
fatal infection have come from carelessness in making these post- mortem 
examinations. 

So far as concerns the character of the wound, which is most likely 
to be followed by septicaemia, there is but little to be said. In a general 
way, wounds made by infected tools, the butcher's knife, the anatomist's 
scalpel, etc., are the most dangerous, and too often those which are so 
small as to either escape observation or be considered too trifling to call 
for treatment. All forms of phlegmonous erysipelas, many cases of 
gangrene following frost-bite, nearly all instances of traumatic gangrene, 
most cases of carbuncle, and, in fact, all similar lesions, are extremely 
likely to be followed by septicaemia. The so-called spontaneous cases 
have an equally infectious origin, though one which is concealed. In 
unrecognized instances of appendicitis, for instance, and in many other 
conditions, although the path of infection may not be easily traced, it is, 
nevertheless, always present, and can be found if diligent enough search 
be made. Too often the nasal cavity, the tonsils, the teeth, the middle 
ear, the deep urethra, and the rectum are overlooked as offering possi- 
bilities for septic infection which may follow this general type. 

Treatment. — This must be both local and general. Local treat- 
ment should consist in complete and absolute removal, so far as mav be 
possible, of the active cause. This will comprise the reopening of wounds, 
evacuation of clot, cutting or scraping away of sloughs and gangrenous 
tissue, with cauterization of the exposed living tissue, in order that 
absorption may not be rather promoted than prevented, and will often 
include such heroic measures as the amputation or extirpation of a part. 
For tissues which are not too completely riddled by disease and lost 
beyond possibility of redemption continuous immersion in hot irater offers 
often the best possible prospect, By it putrefaction seems checked, the 
separation of dead from living tissues is accelerated, relief of pain or 
discomfort is afforded, and prompt disinfection of material which is foul 
and infectious is guaranteed. An excellent local application is the 
mixture, resorcin (5 parts), ichthyol (10 parts), ung. hvdrarg. (40 parts), 
and lanolin (45 parts), already mentioned in Chapter III., or else the 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 103 

application of brewers' yeast, already spoken of in the chapter on ulcers. 
Of greatest value also will now be found the silver ointment of Crede 
(Unguentum CredS). This permits of absorption of silver through the 
unbroken skin (as in the case of ung. hydrarg.), and the dissemination 
throughout the system of the remarkable antiseptic virtues of the silver 
itself. Many cases of septic infection promptly yield under the influence 
of the argentine preparations which Crede has lately introduced. 

In suitable cases, also, the subcutaneous injection, repeated as may 
be indicated, of antistreptococcic serum will be followed by prompt and 
most beneficial effects. As in diphtheria, the earlier the injection be 
given the better the prospect of benefit. 

The general treatment of septicaemia is, in the main, stimulant and 
tonic. Fever is not now to be treated with arterial sedatives nor often 
with antipyretics. It is an expression of poisoning, and its too prompt 
suppression prevents both the recognition of the intoxication and the 
measure of its degree. Pyrexia, then, is best combated with cool 
sponge baths and stimulant measures of a general character. The 
principal reliance must be upon nutrition and stimulants. Assimilation 
must be impaired when gastro-intestinal catarrh is so prominent a fea- 
ture as it is in many of these cases. Consequently, the simplest and 
most assimilable food, often that which is predigested, should be admin- 
istered. Milk, eggs, beef-peptonoids, and fruits are among the most 
appropriate. Of all the stimulants and tonics which the materia meclica 
affords, the two best are alcohol and strychnia. Strychnia is preferably 
administered hypodermically in doses of -^ grain, subcutaneously, from 
two to four times a day, or even oftener. Heart-depression is best 
combated by this measure, or by quinine in large doses, while digitalis 
and atropine may be added if necessary. For internal use alcohol is, 
par excellence, the remedy. This is administered now in doses only to 
be measured by their effect. In fact, the administration of alcohol in 
these cases is a matter of effect, and not of dosage. Aside from these 
measures, the intestinal antiseptics should be administered, among these 
being corrosive sublimate, T -J- ff grain every three or four hours, salol in 
large doses, bismuth salicylate, or naphthaline — any or all of these in 
connection, preferably, with powdered charcoal. Intestinal pain and 
frequency of stool can be more or less controlled by opium, while real 
disinfection of the alimentary canal is only to be accomplished by the 
above remedies, in connection perhaps with flushing of the colon with 
saturated boric-acid solution or something of that kind. Pain is to be 
controlled by morphia administered subcutaneously. 

Pyemia. 

The derivation of the term "pyaemia," which came into general use in 1828, 
is misleading. Although septic fever always accompanies suppuration, it is not 
the case that pus, as such, circulates in the blood, as the term pysemia implies, the 
error having arisen originally from mistaking the contents of breaking-down 
thrombi for pus from ordinary sources. While a recognition of the etiology of 
the disease is new, the disease itself has been recognized for many centuries. 

Pyaemia is only met with in connection with suppuration ; so far as 
known, never without it. In those cases which appear to be free from 
suppuration pus will be found on careful search. Pyaemia may be de- 



104 SURGICAL DISEASES. 

scribed as septicemia plus thrombotic and embolic accidents which lead to 
distribution of infectious material to all parts of the body. This distri- 
bution is, for the most part, made by the blood-vessels, although to 
some extent the lymphatics undoubtedly participate. AVhen pyogenic 
organisms reach blood-vessel walls they often set up a mycotic phlebitis, 
which, by virtue of the coagulating blood, becomes quickly what is 
known as thrombo-phlebitis. Infection proceeding through the vessel- 
walls, the endothelial lining is loosened, while to these rotting spots 
leucocytes adhere and coalesce into a more or less homogeneous mass. 
This so-called white thrombus becomes also infected with bacteria : por- 
tions of it, loosened and dislodged, are carried by the returning blood- 
stream to the right side of the heart, whence they are distributed through 
the lungs. Dislodgement may be by mere force of the blood-stream, or 
may be assisted by movements of the part or handling of the same. 
These particles of thrombi are loaded with the infectious organisms 
which have begun the disease, and wherever each one settles a repro- 
duction of the original thrombo-phlebitis is quickly produced. In this 
way numerous infected thrombi are formed within the vessels of the 
lungs, which, again, loosen, and are now swept into the left side of the 
heart, whence they are distributed with arterial blood in all directions. 
While it is true that they are probably equably distributed, it is also 
positive that certain tissues seem more capable of lodging and being 
attacked by the contained organisms than are others. When it is once 
appreciated that each particle of infected clot is capable of setting up, 
either in the lungs or in the other tissues, upon the second distribution, 
other abscess-formations analogous in etiology to that from which came 
the first disturbance, then, and then only, is the fundamental idea of 
metastatic abscess fully impressed. The term metastasis may be 
regarded as synonymous with transportation, and metastatic abscesses are 
those produced by transportation of infected particles from one part of 
the body to another. Wherever they lodge similar trouble will result, 
providing only that the patient live long enough. Contiguous minute 
metastatic abscesses quickly coalesce, and in this way large collections 
of pus are formed. The blood also contains organisms not attached to 
thrombi, and from the blood of the pysemic patient cultures can be 
made at almost any time. Until this be done it will be virtually im- 
possible to incriminate any particular organism as the one at 'fault. 
Thrombo-arteritis is the equivalent in the arteries of thrombo-phlebitis 
in the veins, and is accompanied by the same detachment of endothe- 
lium, adhesion of leucocytes, etc. 'Whenever such a lesion occurs in 
artery or vein, coagulation-necrosis takes place and suppuration occurs 
around it. The metastatic abscess is thus the result of breaking down 
of this affected tissue, and is often spoken of as miliar if abscess. Parti- 
cles of infective thrombi cling also to the valves of' the heart, and a 
septic- endocarditis may result. 

The possibility of so-called, spontaneous or idiopathic pyaemia is 
occasionally discussed. This means nothing more than a pyemia 
whose cause is concealed. The explanation will be found sometimes in 
an acute infectious osteomyelitis, sometimes in ulcerative endocarditis 
or inflamed appendix or other portion of the peritoneal cavity Again 
it may proceed from middle-ear disease, in which there is so little 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 105 

discharge as scarcely to attract attention. Thus, causes which predis- 
pose to suppuration, which have already been discussed in Chapter III., 
come into play here, and the influence of exposure, fatigue, starvation, 
etc. is not to be ignored in furnishing an explanation for the so-called 
idiopathic cases. 

In the majority of instances, however, pyaemia follows surgical 
operations and injuries, among which are compound fractures, deep 
injuries with small superficial evidence thereof, compound injuries of 
the skull, and injuries by which veins are exposed. Inasmuch as the 
typical pyemic manifestations require a certain length of time for their 
development, the onset of this disease is more delayed than in the case 
of septicaemia. While the case may be manifestly one of septic infec- 
tion of unrecognizable type, the characteristic indications of pyaemia 
seldom appear in less than ten days, and frequently not for several days 
longer. 

Symptoms. — The symptoms of pyaemia do not essentially differ 
from those indicating the other septic infections already mentioned. 
The principal difference is in the frequency of chill and range of tempera- 
ture. Chills are much more common at the inception of the condition, 
and much more frequent throughout its continuance, than in other 
septic conditions. The chill may be slight or assume the proportions 
of a rigor, and each chill is followed by colliquative sweat and exhaus- 
tion. In other words, chills, which are infrequent in septicaemia, are 
common in pyaemia. There is reason to think that with each fresh dis- 
tribution of emboli we have one or more chills as the objective evidence 
thereof. Distinctive also in large measure of pyaemia is the temperature 
curve, which much resembles that of intermittent fever, without the 
regularity of change characteristic of malarial fevers. It is without 
regular remissions, and has been spoken of as irregularly intermittent. 
The first rise is abrupt and usually excessive, while with each fresh 
chill or series of chills similar abrupt alterations will be noted. These 
occur so frequently and fluctuate so irregularly that in order to note 
them accurately the temperature should be taken at least every two 
hours. With all this irregularity, the temperature never drops to 
normal, except possibly toward the last. 

As the lungs fill up with the first crop of infected emboli, and the 
first series of metastatic abscesses form there, there is more or less 
dyspnoea and sense of oppression : there may be also pulmonary compli- 
cations — pleurisy, bronchitis, etc., even pulmonary oedema. Quite fre- 
quent it is to have expectoration of frothy and discolored sputum; 
occasionaliy there is blood in the sputum. A peculiar sweetish odor of 
the breath has been noted by many observers in this disease, and is sup- 
posed to be idiopathic and characteristic. With the dispersal of the 
second crop of emboli from the lungs we are now quite likely to get 
icterus, with, later, evidence of metastatic abscess in the liver, where we 
find large collections of pus as the result of coalescence of small abscesses. 
The sensorium is not so affected in pyaemia as in septicaemia, and in 
the former disease patients are more likely to be alert and active in 
mind. General hypercesthesia and restlessness are common. Colliquative 
sweats are also a feature distinctive rather of pyaemia. There is the 
same liability to eruptions, etc., which may mislead or complicate the 



106 SURGICAL DISEASES. 

diagnosis. There is undoubtedly a dermatitis met with sometimes in 
pyaemia, the lesions assuming a papular or pustular form, due to local 
infections of the skin. Purpuric spots are also seen, and vesication is 
not infrequent, Within the mouth sordes collect quickly upon the 
teeth or gums ; the tongue becomes dry and brown and heavily coated. 
Diarrhoea is less common in pyaemia. The urine is usually scanty and 
high-colored, containing solids in excess ; albumen is sometimes found 
therein, as well as peptone. The presence of peptone in the urine is 
probably an indication of the breaking down of pus-corpuscles in 
various parts of the tissues. 

One most significant objective evidence of pyaemia is met with in 
the metastatic collections of pus within the joints, which occur relatively 
early, and which, if multiple, may surely lead to a correct diagnosis. 
One of the earliest joints to be involved is the sterno-clavicular, 
although none of the joints are free from possibility of invasion. The 
articular serous membranes seem to have the property of carrying and 
holding the infective thrombi better than almost any other tissue in the 
body. The pyarthrosis of pyemia is for the most part painless, yet 
implies loss of function of the affected joints. The distention of these 
is usually evident to the eye, the fluctuation pronounced, tenderness 
not extreme, but the swollen part merges out into tissues which are 
cedematous and reddened. When pain in the limb is extreme, it is 
usually because of metastatic abscess within the bone-marrow cavity. 
In other words, we now have a metastatic osteomyelitis. 

In all cases of pysemia prostration is marked, yet the pulse is seldom 
so weak as would be anticipated, at least until toward the last. As 
cases progress from bad to worse subsultus tend in tint is often noted. 

The appearance of the wound or site of operation, if such there be, 
does not differ essentially from that already described under Septicaemia. 
There is usually, however, less discharge, granulations are smoother and 
dryer, and, if tissues be gangrenous, they are not so offensively wet and 
nasty as in the other case. Evidences of thrombo-phlebitis and lymphan- 
gitis will proceed from the wound toward the body, as in other instances 
of septic infection. 

Prognosis. — Prognosis is almost always bad. While recovery may 
occasionally follow where metastatic infiltration has not been too general, 
the ordinary case of pysemia will die within twelve to fourteen days 
after its recognition. In other instances the entire process is much 
slower, and isolated cases occur which entitle us perhaps to make a 
separate designation for so-called chronic pyarmia, which differs but little 
from the acute form, save in the extreme slowness with which the entire 
programme is gone through. The student should never be unwilling to 
recognize pysemia, as such, simply because he finds no evidence of infec- 
tion from without — e. g. no wound. I have known a fatal case of 
pysemia from a suppurating soft corn which was not discovered dur- 
ing life. Cases are also known from peridental abscesses, etc, which 
had been overlooked. Death is the result of tissue-destruction and 
septic intoxication. It is brought about, however, largely by sheer 
exhaustion. 

Post-mortem Appearances. —In the vessels these consist essen- 
tially of thrombosis, excellent examples of which may be seen for 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 107 

instance, in the cranial sinuses and in the large veins. Aside from 
these, with the enlargement and softening of the spleen, the fiver, and 
lymphatic structures, already described under Septicaemia, the principal 
objective evidences consist in the discovery of metastatic abscesses in 
many or all parts of the body. As stated above, there is no tissue nor 
organ in which they may not be found. The mechanism of their pro- 
duction has been already described. Infarcts may also be met with, in 
the kidneys especially, the liver and spleen as well, and indicate areas 
already cut off from blood-supply by thrombo-arteritis, in which 
abscess-formation would have occurred had time been given. In the 
liver large abscesses may be found ; joint-cavities may be filled with 
pus ; the lungs are usually the site of innumerable small abscesses. 
The other post-mortem changes commonly noted are not difficult of 
explanation, but are not so characteristic nor pathognomonic as to call 
for further mention. In a joint which has become filled with pus there 
has usually been loosening of the cartilage and more or less disorganiza- 
tion of all the joint-structures, which appear to have undergone most 
rapid ulcerative destruction and putrefaction. 

Treatment. — Treatment of pyaemia is in large degree unsatisfactory. 
That which used to be the terror of surgeons in the preantiseptic era is 
now, thanks to Lister and others, almost abolished. Pyaemia is a rare 
disease in modern surgical practice. Its possibility should be borne 
constantly in mind, however, and the necessity for careful antiseptic or 
for a rigid aseptic technique is in large degree based upon fear of pyaemic 
consequences. 

When once established, the disease is to be treated on nearly sim- 
ilar lines to those laid down for septicaemia. Amputation or extirpation 
of the part from which infection has first proceeded may be of avail, 
though usually it will prove too late. Among the most successful, yet 
radical, of measures for surgical treatment of this disease is to expose 
the infected area, freely open the involved veins, and either excise them 
or scrape them out and thoroughly disinfect them. This treatment has 
been particularly successful in certain cases of cranial infection follow- 
ing middle-ear disease, etc. (For more with regard to this work in a 
special location consult the chapter on cranial surgery.) 

That there should be complete disinfection of the infected area, and 
that continuous immersion in hot water, if practicable, should be prac- 
tised, are just as important here as in other septic cases. Metastatic 
abscesses should be opened and freely drained, and every accessible col- 
lection of pus should be evacuated, either by the knife or perhaps with 
the aspirator needle — <■. g. in the liver. 

So far as medicinal treatment is concerned, it is practically the same 
as in septicaemia, while the surgeon's mainstays will be alcohol and 
strychnia. These, with cathartics and intestinal antiseptics, will prac- 
cally sum up the drug-treatment, the surgeon meantime not neglecting 
the matter of nutrition, crowding it in every assimilable form. 



108 SURGICAL DISEASES. 

Erysipelas. 

Erysipelas is an acute infectious disease characterized by its tendency to 
involve the shin and cellular structures, to extend along the lymphatic vessels, 
to involve wounds and injuries under certain conditions, accompanied by 
more or less fever of septic type, leading frequently to septic disturbances 
of profoundest character, yet tending in the majority of instances to spon- 
taneous recovery. It has been observed probably from prehistoric times, 
but has not found a proper description nor appreciation until perhaps 
within the past century. It occurs in so-called traumatic and idiopathic 
form — which latter simply means that the site of infection is not dis- 
covered — and also in a virulent and contagious type, which leads to the 
appearance of a large number of cases over a widespread area of terri- 
tory ; in other words, it often appears in the epidemic form. On account 
of the characteristic reddening of the skin it goes by the suggestive name 
of the rose among the German laity. It may assume the type of an 
infectious dermatitis, subsiding without suppuration, or a similar lesion 
of exposed mucous membrane may be noted, or, occasionally, its viru- 
lence seeming greater, its lesions are met with in more deeply-seated 
parts, accompanied by suppuration or even gangrene, and it is then 
spoken of as of the phlegmonous type. In a small proportion of cases 
the infectious organism appears to be transported from one part of the 
body to another, and thus we have metastatic expressions of this disease. 
The most common expressions of this are seen in erysipelatous meningitis 
after erysipelas of the face or scalp, and erysipelatous peritonitis after 
the disease has manifested itself on the truncal surface. It is of a type 
which makes itself almost interchangeable with puerperal fever ; and in 
time past, when epidemics of erysipelas have involved certain states or 
areas, it has been noted also that nearly every obstetric case developed 
puerperal septicaemia. 

Etiology. — There is more than passing interest connected with this 
last statement. It is now definitely established that the infectious organ- 
ism is a streptococcus which is most strongly allied to, if not identical 
with, the streptococcus pyogenes, the ordinary pyogenic organism of 
this form. 

The specific organism has been separated, studied, and its role assigned 
unmistakably by Fehleisen, and the organism is frequently spoken of as 
Fehleisen's coccus. Preserving always its morphological characteristics, 
it acts, as do many other pathogenic organisms, within wide limits in viru- 
lence. Cultivated from some cases, it scarcely seems infectious, while 
from others it is violently and quickly fatal. 

Pathology. — The disease manifests a remarkable tendency to travel 
via lymphatic routes. So long as it is confined to the skin and super- 
ficial tissues we have the general appearance of an acute dermatitis. 
When it migrates deeper it nearly always leads to suppuration, which 
is another reason for thinking that the streptococci of erysipelas and of 
pus-production are the same. In the affected and infected area the 
minute lymphatics will be found crowded with the cocci, which are seen 
much less often in the small blood-vessels ; also in the tissues beyond 
the apparently infected area they may be found dispersed less freely. 
The bacterial activity seems most active along the advancing border of 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 109 

the superficial lesion. Here the phenomena of hyperemia and phago- 
cytosis are most active. Even in the vesicles that are characteristic of 
the disease the organisms may be found. 

All the discharges from this region are infectious, often in the highest 
possible degree, and extreme caution should on this account be observed 
in any operation, even in dressing such cases. A finger pricked by 
a pin from a dressing may subject the individual to loss of life. The 
dressings containing the discharges should be promptly burned imme- 
diately upon their removal. 

The most frequent path of infection is through some wound, and so 
thoroughly recognized is this fact that it is now a duty upon first recog- 
nition of a case of erysipelas to separate it from all surgical cases, or, if 
the erysipelatous patient cannot be isolated, to remove from his prox- 
imity all other wounded individuals. 

The erysipelas which evidently follows injury, however slight, is always spoken 
of as traumatic. The term "idiopathic" or "spontaneous" should be restricted 
to those cases in which the path of infection is not discovered, and should be 
accepted then as simply an expression of ignorance in this regard. 

Symptoms. — With the exception of the local appearances, they are 
essentially the same in both of the above-mentioned forms. The most 
characteristic feature of the disease is the dermatitis with its peculiar 
roseate hue, which it is impossible to describe in words. In tint it dif- 
fers but very little from that noted in certain cases of erythema. It is, 
however, accompanied by an infiltration of the structures of the skin, 
so that the area which is reddened is at the same time elevated above 
the surrounding surface. Its edges are often irregular. As exu- 
date takes the place of blood in the tissues, the red tint merges into a 
yellow. At this same time there is more induration of the skin and 
more tendency to pit on pressure. Vesication of this involved area is 
now frequent, the vesicles often coalescing and forming large blebs and 
bullae, which fill with serum that may, later, become discolored or puru- 
lent. When exposed to the air, unless the tissues become gangrenous, 
this serum usually evaporates and forms scabs. This disturbance of 
the skin is always followed after a number of days by desquamation. 
This infectious dermatitis shows a constant tendency to spread in all 
directions. Its most characteristic appearances are limited to the margin 
of the enlarging zone, while at the same time in its centre there may 
be evidences of recession of the disease. If it commence in the neigh- 
borhood of a wound, it will probably spread in all directions from it. 
Beginning in the face, it spreads upward usually ; in the trunk, in all 
directions ; while if on the extremities it tends to migrate toward the 
trunk. Wandering erysipelas is a term often applied to these phe- 
nomena. The metastatic expressions of the disease have been already 
alluded to. 

When this infection attacks a recent wound the local appearances are 
not essentially distinct from those already spoken of under Septicaemia. 
The wound-margins separate to a greater or less extent, the surfaces 
slough, and a very characteristic sero-purulent discharge occurs. Gran- 
ulating surfaces usually become glazed — often covered with a membrane 
resembling that of diphtheria ; deep sloughs may occur, undermining of 



HO SURGICAL DISEASES. 

wound-edges, even hemorrhages, from destruction of vessel-walls. In 
rather rare instances, however, under the influence of the microbic stim- 
ulation granulations proceed even faster than normal. 

Whether, now, the disease proceed from an evident injury or not the 
constitutional symptoms vary but little. There is usually a period of 
malaise with nausea, followed by evident alimentary disturbance, coating 
of the tongue, elevation of temperature, sometimes with, sometimes with- 
out, occurrence of chill. Within a short time complaint of pain or 
unpleasant sensation will lead to examination of the area involved, when 
the above symptoms will be noted along with evidences of lymphangitis 
and enlargement of lymph-nodes. When chill occurs it is very promptly 
followed by pyrexia. Temperature fluctuates according to no known 
principles, with a tendency to assume the remittent type. When the 
disease subsides spontaneously, it is by a gradual process of betterment, 
with gradual subsidence of temperature. In other instances the consti- 
tutional symptoms assume more or less of the septiccemic or typhoid type, 
and it is easily appreciated that the patient's condition is practically one 
of mild septicemia, which often becomes serious, sometimes even fatal. 

When, now, the disease assumes the phlegmonous type, the constitu- 
tional symptoms become more and more typhoidal and septicaemia 
becomes most pronounced. Locally, exudation goes on to the point 
of threatening, even of actual gangrene, unless tension be relieved by 
incisions. Pain is usually intense, partly because of confined exu- 
dates beneath unresisting structures. More or less rapidly the local and 
constitutional signs of pus-formation are noted, and unless these be 
observed and acted upon early we will have not only suppuration, but 
more or less actual gangrene, so that not only pus, but sloughs of tissue, 
will be discharged through the incision, or will, when this be delayed, 
make their escape by death of overlying textures. 

In all phlegmonous cases there is practically coincidence of septi- 
caemia, already described, and of the local appearances above noted. 
In proportion to the extent of the lesion in these phlegmonous cases, 
and failure to afford relief, will be the opportunity for septic intoxica- 
tion. 

Even the mucous membrane does not always escape, and in the nose, the 
pharynx particularly, but even in the vagina and rectum, a distinctive erysipe- 
latous lesion may be met with. The disease may travel from the pharynx through 
the nose to involve the face, or through the Eustachian tube to the ear and thence 
to the scalp, or vice vend. Erysipelatous laryngitis is most to be feared on account 
of oedema of the glottis, which would be quickly fatal unless promptly overcome 
by intubation or tracheotomy. An infectious exudation into the lungs is also 
known following erysipelas, and has been considered an erysipelatous pneumonia. 
The cellular tissue of the orbits may also be involved, in which case we will have 
abscesses which should be opened early ; while, again, the parotid and other salivary 
glands may become involved, usually in suppuration. 

Many cases are accompanied by much gastric irritation, which it is 
difficult always to explain. Ulcers are sometimes found in the intes- 
tines, as after burns. These usually give rise to bloody diarrhoea. The 
cerebral symptoms may be simply those of delirium from irritation or 
of meningitis from infection. Strange phenomena have followed the 
disease in certain instances — cessation of neuralgic and of vague unex- 
plainable pain, improvement in deranged mental condition, spontaneous 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. Ill 

disappearance of tumors, etc. Advantage has been taken of this lasb in 
the treatment of these cases. (See Cancer.) 

It is quite likely that some of the worst forms of phlegmonous ery- 
sipelas are due to mixed infection. It is known, for instance, that to 
inject the bacillus prodigiosus together with the streptococcus of ery- 
sipelas will greatly enhance the virulence of the latter, so that reac- 
tion may proceed even to gangrene. 

Post-moetem Appearances. — These are not distinctive, but are a 
combination of local evidences of suppuration and gangrene, with the 
deterioration of the blood, the softening of the spleen, etc., which are 
characteristic of septic poisoning. Only in the skin, and then under 
microscopic examination, can any distinctive pathognomonic appearance 
be made out. This will consist of the crowding of the lymphatic vessels 
and connective-tissue spaces with cocci, in the evidences of rapid cell- 
proliferation, in the quantity of exudate, in vesication, sloughs, etc. 

Diagnosis.— Diagnosis of erysipelas has mainly to be made from 
various forms of erythema, from certain drug-eruptions, and perhaps 
from other forms of septic infection which do not assume the clinical 
type of erysipelas. The gastric symptoms of this disease are some- 
times produced by certain poisonous foods or the distress which is pro- 
duced by medicines, such as quinine, antipyrine, etc. 

Prognosis. — The majority of instances of idiopathic erysipelas run 
a certain limited course, although the eruption may spread to almost any 
distance from the body. When the disease attacks surgical cases, and 
especially when it involves wound-areas, the prognosis is not so good. 
When, too, the disease assumes an epidemic type, and involves indis- 
criminately cases of all kinds, it will be found to have a virulence that 
may make it a most serious affair. In proportion to the extent to which 
it assumes the phlegmonous type it will be found locally, if not gen- 
erally, destructive. The ordinary case of facial erysipelas will get well 
with almost any treatment or perhaps with little or none. Nevertheless, 
unexpectedly, meningitis may develop, and even a mild case is to be 
treated with care and caution, as though one feared disaster. 

Treatment. — Danger comes from two sources — namely, from septic 
intoxication and local phlegmons or gangrenous destruction. Each is, 
therefore, to be combated so far as possible. Treatment, first of all, 
should consist of isolation — this rather for the benefit of others than for 
that of the patient himself. 

Rather in opposition to views held a number of years ago, it must 
be stated that there is no specific internal treatment for this disease. The 
tincture of iron, for example, which was long vaunted as such, has 
proved utterly unsatisfactory, and is of benefit only as a supporting 
measure in a limited class of cases. In general it finds but little field 
of usefulness in this or in any acute surgical disease. Constitutional 
measures should be employed— first, for the purpose of maintaining 
: free excretion by bowels and kidneys ; second, for the purpose of sup- 
porting and maintaining strength ; thirdly, for tonic and, more import- 
ant still, lively stimulant measures to certain thoroughly prostrated and 
debilitated patients ; and, fourth, for the purpose, so far as may be, of 
combating intestinal sepsis or intoxication from any other source. The 
robust patients with this disease need no particular tonic, but these are 



112 SURGICAL DISEASES. 

the patients whom it less often attacks. The aged, the enfeebled, the 
dissipated, the prostrated individuals, and the confirmed alcoholics are 
those who need vigorous stimulation, partly by alcohol and quinine, 
partly by strychnia, preferably given hypodermically, and by the other 
diffusible stimulants by which perhaps alone they may be kept alive. 
Pilocarpine, given subcutaneously and pushed to the physiological limit, 
has been highly praised by some. If, along with prostration, there occur 
restlessness and delirium, then anodynes and hypnotics are most ser- 
viceable, and should be administered to meet the indication — morphia 
hypodermically and any of the agents which produce sleep are now most 
serviceable. Finally, if there be any drug which can be administered 
in doses sufficient to saturate the system with an antiseptic which shall 
at the same time not prove fatal because of toxicity, this is the ideal 
medicament for constitutional use. Such a drug is not yet known, but 
it will be well in many of these cases to give some near approach to it 
internally, as by administering corrosive sublimate, salol, naphthaline, 
or something else of this general character in doses as large as can be 
comfortably tolerated. 

When patients become violent — and they sometimes do in the delirium 
of this disease — it is not only legitimate, but absolutely necessary, to 
resort to mechanical restraint — a strait-jacket, a restraining sheet, a 
camisole, etc. 

Nourishment must also be kept up by the administration of the easily 
assimilable and, if necessary, of predigested foods in sufficient quantities. 

Locally, the number of remedies that have been resorted to in time 
past is legion. In a very mild case of spontaneous erysipelas — i. e. 
where no infection can be traced — it will sometimes be enough to put 
on a simple soothing application, like the lead-and-opium wash of our 
forefathers. It often gives relief to a patient to have the part protected 
from air-contact, which may be done by some soothing ointment or by 
dusting the part with some powder, such as oleates of bismuth sub- 
nitrate, zinc oxide, etc., these being rubbed up with powdered starch 
if necessary. Again, it gives relief to protect by a film of rubber tissue 
or of oiled silk. 

Even before the distinctively bacterial origin of the disease was gen- 
erally accepted it had been suggested to use antiseptic applications, either 
in watery solution or combined with oil or some unguent ; and to-day, 
now that the infectious character of the disease is so completely estab- 
lished, this remains the ideal method of local treatment, the difficulty 
being only to find that which shall be efficacious as an antiseptic, yet not 
injurious in other ways. Compresses wrung out of solutions of various 
antiseptics are often serviceable. Of all the numerous applications which 
I have ever tried, I have found but one thing which has given the 
universal satisfaction aiforded by the following prescription or something 
equivalent to it : Resorcin (or naphthaline), 5 ; ichthyol, 5 ; mercurial 
ointment, 40 ; lanolin, 50. The proportions of these ingredients may be 
varied, and I often increase the amount of ichthyol, especially when the 
skin to which it is to be applied is not too tender. The aft'ected parts 
are anointed with this, and then covered with oiled silk or some imper- 
meable material, simply to prevent its absorption by the dressings ; the 
parts are then enveloped in a light dressing and bandaged. Whenever 



THE SURGICAL FEVERS AND SEPTIC INFECTIONS. 113 

I have to deal with local evidences of .septic infection I use an ointment 
essentially the same as this, and have learned to count on it with more 
reliance than anything that I have ever resorted to. This one better thing 
hinted at above is Crede's silver ointment, which is to be used as described 
above, and has been already alluded to in the treatment of septicaemia. 
As the disease becomes mitigated the ointment may, if desirable, be 
reduced with simple lard, and may be discontinued when local signs 
have disappeared. Absorption of any of these preparations may be 
hastened by a series of scratches over the affected area with the sharp 
point of a knife, not deep enough to draw blood, but deep enough to 
expose better the absorbent vessels of the skin. 

Treatment of threatening phlegmon, or that which is from the out- 
set phlegmonous erysipelas, must be much more radical, and consists 
primarily of free incision down to the depth of the deepest tissues 
involved. For instance, in treating dissecting and other septic wounds 
of the fingers this means incision down to the tendon-sheaths, often 
down to the bone itself. Unpleasant as this may be, possibly even 
crippling, it is only by such radical measures, early put into effect, that 
still worse disaster may be avoided. Finally, some aggravated local 
cases are well treated by a series of deep incisions, even with the use 
of the curette, the surface after careful clearing being kept buried under 
some antiseptic solution (silver-lactate 1 to 500) or ointment. 



CHAPTER VIII. 

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 

ANIMALS. 

By Roswell Park, M. D. 



Tetanus. — Synonyms: Trismus, Lockjaw. 

Tetanus is an acute infectious disease, at present of infrequent occur- 
rence, invariably of microbic origin, characterized by more or less tonic 
muscle-spasm, with clonic exacerbations, which, for the most part, occurs 
first in the muscles of the jaw and neck, involving progressively, in 
fatal cases, nearly the entire musculature of the body. Certain races of 
people seem predisposed, and in certain climates and geographical areas 
the disease is exceedingly prevalent. Negroes, Hindoos, and many of 
the South Sea Islanders show a peculiar racial predisposition, and, in a 
general way, inhabitants of warm countries are less resistant. This is 
shown partly by the fact that in various European wars the Italians and 
French have suffered more than the soldiers of more northern climes. 
Tetanus is by no means confined to adult life, since infants are far from 
exempt, and in the tropics the trismus of the new-born is the cause of a 
high mortality-rate. In Jamaica one-fourth of the new-born negroes 
succumb within eight days after birth, and in various other hot countries 
the proportion is at times equally great. One plantation-owner states 
that fully three-fourths of the colored children born upon his plantation 
succumbed to the disease. The peculiar reason for this infection will 
appear a little later when speaking of tetanus neonatorum. Men seem 
more commonly aifected than women, probably because of their occupa- 
tions, by which they are more exposed. Military surgeons have had to 
contend with the disease in its most frightful form, and it has been noted 
that soldiers when worn out by fatigue or suffering from the disaster of 
defeat seemed more liable to the disease. In 1813 the English soldiers 
in Spain suffered from tetanus in the proportion of 1 case to 80 wounded 
men. In the East Indies, in 1782, this proportion was doubled. Quick 
variations of heat and cold, such as warm days and cold nights, coupled 
with the other exposures incidental to military life, seem to exert a great 
effect. Curiously enough, the wounded in many campaigns who have 
been cared for in churches have suffered more from the disease than those 
cared for in any other way. Tetanus, however, is by no means neces- 
sarily confined to any one clime or race, but may be met with anywhere, 
at any time, providing only that infection have occurred. A celebrated 
Belgian surgeon was unfortunate enough to lose by tetanus 10 cases of 

1L4 



DISEASES COMMON TO MAN AND ANIMALS. 115 

major operations before he determined that the source of the infection 
pertained to his hsemostatic forceps. So soon as these were thoroughly 
sterilized by heat he had no further undesirable complications. If the 
disease can be so conveyed by the instruments of a careful surgeon, how 
much more so by the dirty scissors of a careless midwife, etc. ! 

It is true, also, that the popular notions of the laity concerning the liability to 
tetanus after certain forms of injury are not ill-founded. Small ragged wounds of 
the hands and feet are those which ordinarily receive little or no attention, and 
are among those most likely to be followed by this disease. The toy pistol, which, 
a few years ago, was such a prevalent and widely-sold children's toy, was guilty of 
many a small laceration of the hand, due to careless handling and the peculiar 
injury produced by the explosion of a small charge of fulminating powder in a 
paper or other cap. It was not the character of the laceration or injury thereby 
produced, but the fact that such injuries occurred in the dirty hands of dirty chil- 
dren, which were most likely to become infected, that has caused the so-called toy- 
pistol tetanus to be erected almost into the dignity of a special form of this disease. 
During the month of July of 1881, in Chicago alone, there were over 60 deaths 
from tetanus among children who had been injured in this way by these notorious 
little toys. This led to their sale being suppressed by law. 

Etiology. — In time past two theories have had strong advocates, 
one being that which would account for the disease by irritation of 
nerves — a nervous theory ; while the second, the humoral, would explain 
the disease by alterations in the blood. Each has had its most ardent 
defenders, but both have now completely yielded to the investigations 
of a few observers, among whom Kitasato and Nicolaier are the most 
prominent. These ardent workers 
have been able to clearly establish 
the parasitic, nature of this disease 
and to isolate and investigate the 
organisms by which it is produced. 
This was in 1885. 

The bacillus of tetanus is a somewhat 
slender rod-shaped organism, with a pecu- 
liar tendency to spore-formation at one 
end, which gives it a drumstick appear- 
ance. It is essentially an anaerobic or- 
ganism, and can never be cultivated in 
contact with the air. In laboratory experi- 
ments it is grown in the depths of a solid 
culture-medium or else in fluids and on 
surfaces in an atmosphere of hydrogen 
gas. It is one of the apparent contra- 
dictions of bacteriology that this organism, 

which can only be grown as an anaerobe, Tetamls bacim showing apore . format j on 
nevertheless abounds in earth, particu- (Kitasato). 

larly the rich black loam which best sup- 
ports luxuriant vegetable life, and that it practically inhabits the upper layers of 
the soil, which accounts for the fact that so many contaminations and infections 
have occurred from stepping upon planks or boards with nails projecting, or from 
introduction of splinters, or from lacerations of the hands and feet which are so 
often followed by contact with such materials. There is nothing about a rusty-nail 
wound which, by itself, predisposes to tetanus, but the rusty nail upon which the 
barefooted boy steps is either itself infected or leaves a rent or wound which the 
boy may infect within the next few moments, and which is not likely to receive 
the careful attention which it ought to have. Verneuil has of late laid stress upon 
the fact that in localities where horses are kept tetanus is more prevalent, and that 
the infectious organism abounds in and upon stable-floors, about barn-yards, and 
wherever the excretions of a horse may be found. Bacteriologists are all aware 



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116 SURGICAL DISEASES. 

that in the intestine of herbivorous animals the bacilli (anaerobic) of tetanus and 
malignant oedema are often found. Verneuil has further shown that almost the 
only instances of tetanus which occur on shipboard are upon those ships which 
are used for transportation of horses and cattle. His statements are at least 
interesting, if not absolutely well founded. At all events, tetanus is certainly of 
telluric origin. 

A French veterinary surgeon of twenty-five years' experience had not seen a 
single case of tetanus until 1884, when he "removed a tumefied testicle from a 
horse with the ecraseur, and it died of tetanus ; in the following six months he 
castrated five, and they all died ; another castrated fifteen in one day, and they 
all died but one ; another in ten days castrated six bulls and operated on three 
fillies for umbilical hernia; five of the bulls died and one of the fillies." This will 
illustrate how the infectious agent may be conveyed by instruments, etc. 

The tetanus bacillus manifests other peculiar properties, for some of which it 
is most difficult to account. Upon susceptible animals it is violently infectious, 
but is very rarely found at any distance from the tissues in which it has first lodged, 
and it has never been satisfactorily demonstrated far away from them. In labora- 
tory investigations the period of incubation is seldom longer than forty-eight hours. 
Another peculiarity of the organism is that it generates certain poisoDS of most 
active properties which may be separated from pure cultures, by whose injection 
the peculiar spasms of the disease itself may be reproduced. These have been 
isolated, especially by Brieger, who has given to them the names of tetanin, tetano- 
toxin, spasmotoxin, etc. 

Tetanus neo-natorum, or tetanus of the new-born, a condition already 
alluded to, is a remarkably fatal affection, very prevalent among the 
negro race, especially in hot climates. It in no wise differs from trau- 
matic tetanus, but is such in effect, since the infection in these instances 
always follows the division of the umbilical cord, which is usually effected 
by dirty scissors in the hands of a dirty midwife, while the thread with 
which the cord is tied is itself a possible source of infection, as well as 
the rags which are used to cover the umbilicus in the first dressing. It 
is virtually always fatal, because of the weakness and lack of resistance 
of these little patients. It occurs usually within a week after birth, if 
at all. Tetanus cephalicus, called also tetanus hydrophobicus and head- 
tetanus, is only a peculiar manifestation of this same affection, confined 
for the most part to the head and usually following injuries to this 
region. The muscle-spasms are, for the most part, confined to the 
facial, pharyngeal, and cervical muscles, sometimes extending to the 
abdominal. These manifestations may be in some measure reproduced 
in animals by inoculating them on the head rather than upon the extrem- 
ities. It is the least fatal form of the disease. 

Symptoms. — There is always a, period of incubation , usually three or 
four days, occasionally a week in length, and rarely considerably longer. 

It is generally held that the longer the period of incubation the more 
hopeful the prognosis. While for the most part the disease assumes a 
most acute type, a chronic tetanus is described and occasionally met with. 
The first warning of the disease usually comes as more or less stiffness 
of the cervical and maxillary muscles, which is likely to be spoken of by 
the patient as a " sore throat," because of the consequent difficulty in 
deglutition. A complaint to this effect should be always regarded as a 
warning, especially if, on inspection, no visible reason for it can be 
detected in the pharynx. This complaint is usually made in the morn- 
ing after an ordinary night's rest. This muscle-stiffness will be followed 
by increasing tonic spasm in the muscles of the jaw, making it difficult to 
open the mouth, while the head and neck gradually become stiffened 



DISEASES COMMON TO MAN AND ANIMALS. 117 

and fixed by spasm of the cervical muscles. These muscles may now 
be felt more or less rigidly contracted, as if by voluntary effort, and the 
condition, which is at first not painful, becomes after some hours a source 
of discomfort, perhaps of actual pain, to the patient. If, now, the disease 
pursue the usual course, the other muscles of the body become grad- 
ually affected, usually in the order of their proximity, but not necessarily 
so. The abdominal muscles are firm and board-like, and the dorsal mus- 
cles more or less contracted, sometimes to an extent which causes arching 
of the spine. Should the original wound or port of entry for infectious 
germs have been in the hand or foot, the muscles of this limb become 
contracted, more or less rigidly, holding it in a position which is not easily 
changed, even by efforts of the attendant. Sensation is also often more 
or less perverted. In this condition of tonic rigidity the muscles remain, 
to relax usually only with death. 




Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure culture of 
tetanus bacilli (lizzoni and Cattani). 

The most characteristic features of the disease, however, are the pecu- 
liar clonic exacerbations, which convert spastic 'rigidity into violent and 
convulsive muscle-activity, so that the limbs, and even the frame, of the 
patient are more or less contorted, the muscle-exertion being sometimes 
most painful to witness. Peculiar effects are thus produced : the mouth 
is peculiarly puckered, and its corners drawn upward and backward by 
the risorius muscles, giving to the face that peculiar expression known 
as the " sardonic grin." When the abdominal and flexor muscles of the 
thighs are especially involved, the body is more or less curved forward, 
and this is known as emprosihotonos. When the muscles of the back 
especially are involved, with the extensor muscles of the thighs, we have 
opisthotonos, while, when the body is bent to one side or to the other, it 
is spoken of as pleurosthotonos. It is said that opisthotonic convulsions 
occur to such extent in rare instances that the heels may even touch the 
head. At all events, the patient's body is frequently raised from the 
bed, so that he rests upon the head and feet. 

Another most characteristic feature of the disease is the peculiar 
reflex irritability or hyperesthesia by which these convulsive attacks 
apparently are produced. Into this one falls more or less rapidly within 
the first day after the inception of the disease ; and to such a height 
may it be augmented that the slightest movement in the room, jarring 
of the bed, or displacement of clothing, even noise or a flash of light, 
may immediately bring on a convulsion. Eupture of muscles has been 
reported during some of these violent convulsions. 



118 SURGICAL DISEASES. 

During the coarse of this disease the jaws are so fixed that patients 
speak with extreme difficulty and the tongue cannot be protruded. The 
mind is clear until the end. The pain is rather the acute soreness due 
to intense muscle-strain. There is spasm of sphincters by which urine 
and feces are often retained. There is nothing characteristic about the 
temperature, which is seldom much augmented. Attempts to swallow 
give pain, and are resisted specially because of the renewed muscle- 
spasm which is likely to follow the irritation inseparable from the act 
itself. As the result of spasm of the glottis peculiar respiratory sounds 
may be noted. 

Until the last only the voluntary muscles are involved. Finally, however, 
come spasms of the accessory respiratory muscles, and, lastly, of the diaphragm ; 
and death is usually produced by involvement of these muscles analogous to that 
of the others. Death results, then, usually from apnce.a or suffocation.^ During the 
last hour or two perspiration may be copious and temperature may rise. 

Chronic tetanus is characterized throughout by a milder and much 
more prolonged series of symptoms. The period of incubation is much 
longer, and, while the general programme of the acute form is adhered 
to, it is of less severe degree and is spread over a longer time ; in fact, 
cases covering two months or more are reported. In chronic tetanus 
the prognosis is much more hopeful than in the acute form. 

So far, nothing has been said about the appearance of the wound. 
This is but slightly, if at all, affected. In some cases it will be found 
to have completely healed before the onset of the disease. If suppu- 
rating or open, its evidences of repair will be found unsatisfactory and 
some indications of septic infection may be noted. Pricking or needle 
sensations may be subjective phenomena. 

Prognosis. — Prognosis is almost invariably bad. No case of acute 
tetanus under my own observation has ever yet recovered. Still, occa- 
sionally recovery does ensue. Whether this be due to a peculiarity of the 
patient or to the medication is, perhaps, still doubtful. If patients live 
more than five or six days, the prognosis is thereby certainly bettered. 

Post-mortem Appearances. — These are rarely distinctive. In 
most instances there are evidences at least of hypersemia, if not of more 
active changes, in the upper portions of the cord. Much less often 
slight changes have been noted in the brain, consisting, in some measure, 
of disintegration and softening. Evidences of ascending neuritis in the 
nerve-trunks leading to the injured area have been claimed in some 
instances. As a matter of fact, however, few, if any, distinctive post- 
mortem changes can be described as due to this disease. 

Diagnosis. — This must be made as between strychnia-poisoning, 
hysteria, hydrophobia, tetany, and, in the very beginning, from pharyn- 
gitis, tonsillitis, etc. When the disease is fully developed it is not likelv 
to be mistaken for anything else. 

Tetanus may be simulated by hysteria in patients of a certain class, but in this 
event the phenomena will be so uncertain, so contradictory, and the evidences of 
real organic disease so essentially lacking, that it is not likely that mistake can occur. 

Treatment. — If any case can be imagined in which efficient treat- 
ment is most urgently demanded, it is one of tetanus. In scarcely any 
disease, however, is treatment so unsatisfactory. In the rare instances 
in which patients recover one questions whether it is not due to indi- 
vidual resistance rather than to medication. Treatment may be sub- 



DISEASES COMMON TO 31 AN AND ANIMALS. 119 

divided into heal, constitutional, and specific. If there be still an open 
suppurating or discharging wound, it is well to anaesthetize the patient 
and to thoroughly cleanse this out, basing this advice in some measure 
upon general principles — largely upon the fact, already stated, that only 
the immediate surroundings of such a wound are found infected by the 
bacilli themselves. Consequently, thorough scraping, excising, and 
cauterization , either with powerful caustics or the actual cautery, are 
indicated. If it be in a finger or toe, amputation may be the simplest 
method of eradicating the local lesion. 

Constitutional treatment may be divided into nutrition and medication. 
The tendency too often in these cases is to be careless or indefinite with 
regard to the excretions and the nutrition of the patient. If, for instance, 
each attempt at catheterization throw him into convulsions, the bladder 
may become over-distended, and even may possibly burst. So, too, there is 
apprehension usually with regard to fecal evacuations. At the same time, 
these patients are allowed to almost starve because of the difficulty of 
feeding them. My advice first, then, is to resort to chloroform at least 
often enough to permit the introduction of a stomach-tube — through the 
nostrils, if necessary — by which nutrition may be introduced into the 
stomach without causing the violent convulsions that would certainly 
occur without an anaesthetic. At the same time, the catheter may be 
used if necessary. 

In the way of active medication there is no agent so efficacious for 
controlling the tetanic spasms as chloroform, which may be administered 
occasionally, or more or less continuously, according to the wishes of the 
attendant. By its use the severest spasms at least can be kept in abey- 
ance, and the horrible character of the disease somewhat mitigated. 
Of the other medicaments used, most of them are of the nature of 
nerve-sedatives, such as chloral, the bromides, Calabar bean, cannabis 
ind.ica, opium, etc. By continuous but mild dosage with Calabar bean 
(eserine, hypodermically) the severest manifestations can often be, in a 
measure, controlled, providing only it be given in small doses. 

Curare, on account of its peculiar effect in paralyzing voluntary mus- 
cles, has been suggested and frequently resorted to. On account of the 
difficulty of getting a reliable specimen, it is not always at hand, and 
even then one must experiment with it in order to learn the exact dose 
of a given specimen which the patient can safely tolerate. Hot-air 
baths or diaphoretics, by which copious perspiration may be induced, 
have yielded good results in certain cases. In fact, they were in general 
use several centuries ago. Cold applications down the spine, or spraying 
the spinal region with ether or other volatile substances by which heat 
is abstracted have also had their advocates, the intention being to pro- 
duce spinal anaemia, so far as possible, as the reflex result of external 
cold. But to do this means to disturb the patient, and the practice has 
not been generally followed. 

Specific treatment means in these instances taking advantage of the 
now well-known properties which the blood-serum of an animal artifici- 
ally immunized against the disease possesses. This is in accordance with 
recent experimental labors with a number of different diseases, of which 
tetanus is one. It is, in effect, similar to the serum-therapy of diphtheria 
so recently introduced. 



120 SURGICAL DISEASES. 

The most hopeful modern remedies are formalin, injected about the 
injured area, in very weak solution (say 1 to 1000), and especially the 
antitoxin now prepared in several laboratories in this country, and to-day 
quite easily procured. More lives can be saved by this preparation, if 
Used early enough and freely enough, than by any other known remedy. 
It is of vital importance, however, to use it at the very outset, and to 
repeat its use as soon or as often as may be indicated by any exacerba- 
tion of symptoms. In a few cases great benefit has seemed to accrue 
from introducing it within the dural space, or even within the cerebral 
substance, after making one or more small trephine-openings. The 
writer was the first in this country to adopt this suggestion from France, 
and believes in the value of the method in selected cases. 

Hydrophobia. 

Hydrophobia is an acute specific or infectious disease, so far as known 
never originating in man, but transmitted to him, usually through the bite 
or by inoculation from the saliva of a rabid animal — in this country 
iisually the dog, although the wolf, the cat, the skunk, and even certain 
of the domestic poultry, are capable of conveying the disease. It can 
also be inoculated in other animals, like rabbits. The virus is ordinarily 
conveyed in the saliva of the rabid animal. This may be wiped off as 
the teeth of the animal pass through the clothing of the injured indi- 
vidual ; consequently, infection does not certainly follow such bites. 
But those upon exposed portions of the body, where animals generally 
bite, are almost invariably followed by infection. Hydrophobia is fre- 
quently spoken of as rabies, sometimes as lyssa. While rare in this 
country, it is by no means rare in Central Europe, especially perhaps 
in Russia, where bites from infuriated wolves are relatively common. 
In the United States infection comes almost invariably from the rabid 
dog, in whom this disease presents two types. 

The so-called furious form is that which is marked by frenzy and canine mad- 
ness, the objective symptoms being more pronounced and alarming, though not less 
dangerous, than the other variety. After the period of incubation, which varies 
considerably, these animals show depression and uneasiness, and even thus early 
their saliva is infectious. Their sense of hunger becomes perverted ; they exhibit 
unusual tastes, secrete saliva abundantly, which becomes very tenacious and even 
frothy, exhibit a dry and cedematous condition of the faucial mucous membranes; 
the character of the bark is altered, while they are usually infuriated at the sight of 
other dogs. In this stage there is usually insensibility to pain. Finally, come 
more or less paralysis of deglutition, quickened respiration, dilated pupils, and 
frenzy and madness of manner, by which they attack indiscriminately men and 
other animals. To this stage of furious excitation succeeds one of paralysis, and, 
finally, death follows from exhaustion. These manifestations usually last about a 
week. 

Dumb hydrophobia is the more common form. Here paralysis appears much 
earlier and involves especially the lower jaw ; the tongue falls out ot the mouth ; 
and the posterior extremities are quickly paralyzed. This form is much more 
quickly fatal than the other. 

Hydrophobia in man is rare in this country, yet is occasionally met 
with. Its etiology is as yet completely obscure. That a contagium 
vivum is present is positive, but its nature is absolutely unknown. 

Symptoms. — The period of incubation in man is very variable, ten 
weeks being perhaps the average. It is shorter in children, as also when 



DISEASES COMMON TO MAN AND ANIMALS. 121 

the bites are numerous. It is even stated that it may be so long as a 
year or more, during which time the poison seems to lie latent. When 
the active symptoms supervene there are, locally, discomfort about the 
wound, itching, heat, and peculiar unpleasant sensations. It is said also 
that, in some cases at least, vesicles make their appearance in the neigh- 
borhood of the original lesion. As in animals, so in man, the disease 
may assume either the furious or the paralytic type. These cases are 
nearly all marked by mental depression and apathy, with complete loss 
of courage. The earlier symptoms are connected perhaps with the 
respiration, which is infrequent, while inspiration is halting and speech 
is interfered with. The facial appearance is often changed to one of 
anxiety, even despair. The muscles of deglutition are next involved 
in a combination of spasm and paralysis, and the act of swallowing is 
interfered with, sometimes made almost impossible. Although patients 
can swallow their own saliva, thev find it most difficult to swallow any 
foreign substances, such as water, etc. This is not due to the fear of 
water, as the term " hydrophobia " would imply — -this being an absolute 
misnomer — but is due to reflex spasm excited by the attempt. It is 
accompanied by more or less sense of suffocation and palpitation of the 
heart. Indeed, a paroxysm of this kind may be precipitated by the 
attempt to swallow, so that the patient instinctively refuses water or any 
other fluid. Reflex excitability is also very great, and a breath of air or 
a trifling disturbance may precipitate a paroxysm, almost as in extreme 
cases of tetanus. As the case progresses the saliva becomes more tena- 
cious and viscid, faucial irritation more marked, and the attempts to 
expel the secretion, along with the disturbed respiratory efforts, have 
given rise to the foolish lay notion that these patients bark like dogs. 
The paroxysms, as the case progresses, become more marked, the patient 
more restless, until, later, furious mania or muttering delirium is present, 
to be followed by prostration and paralytic phenomena, muscle-tremor, 
etc., and death. 

The paralytic form in man, as in dogs, is marked by the much earlier paretic 
phenomena, anaesthesia, and, finally, respiratory paralysis, which terminates the 
case. Curtis and others have insisted that the hydrophobic paroxysms are not 
convulsions in the ordinary sense of the term, but are due to temporary inhibitions 
of the most important respiratory and cardiac centres as the result of peripheral 
impressions. He would liken them to the shock of a shower-bath. 

Post-mortem Changes. — Post-mortem changes are indistinct and 
only suggestive. For the most part they are found within the nervous 
centres — most prominently in the medulla, then in the hemispheres, and 
then in the spinal cord. There is hypersemia, with minute ecchymoses, 
with infiltration of the adventitia of the vessels and perivascular extrav- 
asation. The changes met with in the other viscera bear no constant 
relation to symptoms. Nevertheless, Gowers holds that because of the 
location of the lesions and their intensity in the neighborhood of certain 
nerve-nuclei we have here a distinguishing anatomical character. of the 
disease. 

Diagnosis. — As between hydrophobia and tetanus, diagnosis is not 
difficult, as already described. In certain hysterical individuals nervous 
paroxysms, largely due to fright, may be precipitated by dog-bites and 
other incidents or accidents. In these cases there is rarely, if ever, such 
a period of incubation, and in a true hysterical case there will be no 



122 SURGICAL DISEASES. 

such mimicry, of this awful disease. A condition known as lyssophobia 
(fear of hydrophobia) has been described. It is seen for the most part 
in hysterical subjects. It is said to have even been fatal, but this must 
have been from other complications. 

Treatment. — There is no authenticated case on record of recovery 
after medication by drugs. It is probable that recovery has never fol- 
lowed anything save the modern inoculation-treatment. 

The essential and only successful treatment for this disease has been 
elaborated as the result of the labors of that indefatigable French 
savant, Pasteur, and is among the most glorious triumphs of laboratory 
research, against which it is so often charged that it is not practical in 
its results. It is in some respects a curious commentary on the study 
of infectious disease that we can secure and work with the peculiar virus 
of hydrophobia, and at the same time be utterly unacquainted with its 
true character. To this fact is due the modern cure. It is based upon 
the fact also that the virus obtains not only in the saliva, but in the 
nervous system of animals suffering from this disease ; also to the fact 
that its effects are intensified and hastened by inoculation directly into 
the cerebral substance. 

Virus obtained from the brain or cord and inoculated into the dura of another 
animal quickly precipitates the disease. It is, moreover, modified in virulence as 
it passes through successive animals of certain species — for example, monkeys. 
Curiously enough, it is increased by passage through rabbits, and the period of 
incubation thereby shortened. The weakest virus can by proper handling and 
manipulation in this way be so intensified as to produce disease within seven days 
after inoculation. Desiccation reduces the virulence, and preparations from the 
cord of an infected animal may be attenuated to almost any desired extent by 
drying. By inoculating a dog or a rabbit, for instance, with virus prepared from 
this weakened source, and daily making injections from stronger and stronger 
preparations, he is in the course of a couple of weeks rendered practically immune 
to the disease. Animals thus made immune are trephined, and the virus injected 
beneath the dura, by which much more certain results are obtained. 

Glanders and Farcy. 

Glanders as it is ordinarily known in man is a specific infectious dis- 
ease, transmitted, for the most part, from the horse, characterized by rapid 
formation of specific granulomata, particularly in the skin and mucous 
membranes, which quickly break down into ulcers, and by the general 
toxaemia of any acute infection. In German it is known as rotz ; in 
French, as mar re; while its old Latin name was "malleus" (hence 
we speak of the bacillus mallei). It was also known in former davs as 
equinia, In horses the disease has also been known as farcy, because of 
the peculiar subcutaneous nodules which farriers and hostlers almost 
from time immemorial have called " farcy buds." The disease, while 
capable of transmission from man to man, is virtually always produced 
by contagion from some of the domestic animals, most commonly the 
horse, although sheep and goats are known to occasionally have it, and 
dogs are quite susceptible, though seldom showing manifestations of it. 

Like some of the other infectious diseases, glanders appears to be variable in 
its manifestations. While infection occurs probably through some superficial 
abrasion, it is almost certain that it may also occur through the unbroken mucous 
membrane of the respiratory organs. It is said to be also capable of transmission 
from mother to foetus in utero. So far as known in man, infection occurs practically 
invariably through some slight abrasion, either of the skin or the mucous mem- 



DISEASES COMMON TO MAN AND ANIMALS. 123 

brane of the nose, the eye, or the mouth. The discharges from the nostrils of 
affected animals are extremely virulent, and infection comes usually from this 
source. It is said to have been communicated from one patient to another by eat- 
ing from the same dish or by drinking from a pail used by a diseased horse. 

Glanders is due to the specific bacillus known as the bacillus mallei. 
It is shorter and plumper than the tubercle bacillus, in length about 
one-third the diameter of a red corpuscle. It is a non-motile organism, 
occasionally spore-bearing, not very resistant, belonging to the facultative 
anaerobic forms, growing best at blood-temperature, taking stains easily, 
and losing them in the same way. 

Symptoms. — Glanders is met with almost invariably in workers and 
hangers-on in stables. The acute — the common — form has a period of 
incubation of from three to seven or eight days, after which both local 
and general symptoms supervene. About the infected region a form of 
cellulitis appears, assuming often a more or less phlegmonous type, 
with implication of the adjacent lymphatic nodes and evidences of 
periphlebitis and perilymphangitis. Over the affected area vesicles 
appear, which become hemorrhagic, and later suppurate. A wound 
which has healed may reopen. Almost always there are accompanying 
constitutional disturbances of septic type, occasionally chills, pyrexia, 
etc. It is rather characteristic of glanders to have severe pain in the 
muscles and extremities, with epistaxis and formation of metastatic 
tumors and oedematous swellings in various parts of the body. Fre- 
quently, later in the disease, comes a somewhat distinctive eruption, 
papular in character, merging into pustular. Hemorrhagic bullae are 
also often seen. Pustulation and oedema of the face change its appear- 
ance notoriously. There take place also oedema of the eyelids and muco- 
purulent discharge from the conjunctiva and the nose. This latter dis- 
charge is often even ozaenous in character. Upon inspection of the 
naso- and oro-pharynx a similar condition will be noted. In connection 
with these local signs more or less general furunculosis will also be 
observed. Obviously, as these local conditions intensify and multiply 
septic disturbance will be increased, and the patient dying of acute 
glanders dies in large measure of septicaemia or intoxication and exhaus- 
tion combined. 

A chronic form is known, distinguished mainly by slowness or tardiness of 
lesions, though the local changes are not particularly different in character. There 
is perhaps more tendency to suppuration and less to lymphatic complications. The 
nodule which breaks down will leave a foul ulcer, the discharge from all these 
lesions being extremely infectious. 

Diagnosis. — This is not always easy, but may be based in suspicious 
cases to some extent upon the occupation of the patient. The presence 
of multiple lymphatic lesions and subcutaneous nodes, especially when 
breaking down as above described, and accompanied by ozaenous dis- 
charge from the nose, should at least be most suggestive, and will serve 
to distinguish between this disease and, for instance, typhoid fever. 
The chronic type of glanders might be mistaken for syphilis, and here 
is where the real difficulty of diagnosis will probably obtain. In doubt- 
ful cases the crucial tests would be microscopic examination of discharges 
after staining for bacilli, and the cultivation test. 

Prognosis. — A generalized attack of glanders is a matter of gravest 
import, especially when acute. Scarcely more than 10 or 15 per cent. 



124 SURGICAL DISEASES. 

of such cases recover. In the more chronic manifestations the prognosis 
is very much better, half of the patients making a final recovery. 

Treatment. — All infected animals should be quickly isolated and 
destroyed, their carcasses being burned. If possible, the infected wound 
or abrasion should be coaxed to bleed freely, and then cauterized with 
some active caustic. By prompt interference with the first manifesta- 
tions it may be possible to cut short the disease. This would necessarily 
be done by excision, cauterization, packing, etc. Bayard Holmes has 
reported a case in which, during two and a half years of chronic mani- 
festations of this disease, he anaesthetized the patient twenty times for 
the purpose of opening new foci or scraping out old ones, finally obtaining 
a permanent cure. There is no specific treatment, but the septic symp- 
toms should be combated as already indicated in the chapter on Sep- 
ticaemia. 

By making a glycerin extract from the filtered and evaporated culture of the 
glanders bacillus it is possible to prepare a toxalbumen analogous to tuberculin, 
which reacts in a similar way. By it animals may be fortified against inoculation, 
and by its use a peculiar reaction is produced in those affected by the disease. It 
is known as mallehi, and by it are tested all horses used for the preparation of the 
diphtheria antitoxine, in order that all possibility of glanders may be eliminated. 
It is probable that it might be made of therapeutic value in treating the disease 
when actively present in man. 

Anthrax. 

Anthrax is more commonly known as splenic fever, malignant pus- 
tule, or wool-sorters' disease; in Germany, as Milzbrand, and in France, as 
charbon. It is an infectious disease of cattle, which has devastated 
many parts of Central Europe, and which has been frequently met 
with abroad among men, though but rarely in the United States. All 
the domestic and nearly all the experimental animals are subject to it. 
Gronin has stated that in the district of Novgorod, in Eussia, during four 
years more than 56,000 cattle and 528 men perished from anthrax. Poul- 
try and dogs are not exactly immune, but possess a low susceptibility to 
the disease. It seems to prevail in low districts and in marshy grounds. 

The disease is the result of the invasion of the bacillus anthracis, 
which is a relatively large-sized bacillus, varying in breadth from 1 to 
11 and in length from 5 to 20 mikrons. It is most easily cultivated 
outside the body, and multiplies with great rapidity in the body of sus- 
ceptible animals, is the type of spore-bearing bacilli, and is "so easily 
recognized and worked with that it is commonly used in laboratory 
investigations. The demonstration of its specificity we owe to Davaine 
in 1873, although he had described it in 1850. 

Anthrax bacilli may enter the body through the respiratory organs, 
through any abraded surface, and possibly even through the alimentary 
canal. They may also pass through the placenta and affect the foetus 
in utero. They are too large to pass through the walls of the capillaries 
of ordinary size ; consequently, they plug them and produce a mechan- 
ical stasis which is rapidly followed by gangrene. From the kidney 
structures and capillaries, however, they must escape, since bacilli are 
found in the urine in certain cases of anthrax. 

In man the disease occurs usually as the so-called malignant pustule 
or ivool-sorters' disease, the latter name being given because of the 



DISEASES COMMON TO MAN AND ANIMALS. 



125 



Fig. 22. 




Bacilli of anthrax : section from liver ; X 500 
(Friinkel and Pfeiffer). 



liability of those individuals who come in contact with the carcasses 
and hides of diseased animals or their immediate products. The period 
of incubation is brief — on the average 
two or three days. The first lesion 
appears usually on the face, hands, or 
arms, and is characterized by local 
discomfort with formation of a small 
papule, which rapidly becomes a ves- 
icle with an areola of cellulitis about 
it. This is rapidly followed by indu- 
ration and infiltration, and these by 
local gangrene, the result being the 
separation of a core-like mass, much 
as in certain cases of carbuncle. The 
affected area is usually discolored, 
often quite black. The process is not 
usually accompanied by suppuration, 
nor is there the pain of true carbuncle. 
The lesions tend to spread peripher- 
ally, but there is more or less vesi- 
cation of the surrounding skin. On 
account of the local ischaemia there will always be cedema of the affected 
region, and sometimes the swelling and local disturbance become ex- 
treme. These peculiar lesions have given rise to the common name, 
malignant pustule, which is well deserved. At last a line of demarca- 
tion becomes manifest, and if the disease progress favorably the included 
area is sloughed out, leaving a surface which it is hoped will soon become 
covered with reasonably healthy granulations. 

Absence of pain, and usually of pus, are significant features of anthrax. 
Should, however, mixed infection occur, wo are quite likely to get pus- 
formation. When the disease partakes less of the characteristics of 
malignant pustule and more of a general infection, the local symptoms 
may not predominate, but, on the contrary, septic indications may be- 
come serious and even fatal. The evidence of more or less toxa?mia 
is usually at hand, however, and the toxine of anthrax is almost as 
destructive of muscle-cell integrity as is that of diphtheria. 

The local lesions may be single or multiple, but will be met with 
almost always upon exposed areas of the body. 

Post- mortem Appearances. — These will depend upon the clinical 
course of the disease. In the sloughing tissues the bacilli are very 
numerous, while around the margin more than one bacterial form will 
probably be met with — i. e. mixed infection. Should saprophytic organ- 
isms complicate the case, they may have replaced the anthrax bacilli 
by the time the examination is made. The latter abound, however, in 
the blood, and may usually be found occluding the capillaries of the 
liver, spleen, kidney, etc. In intestinal infection, particularly in ani- 
mals, the mesenteric nodes are involved. Inasmuch as septic features 
accompany all fatal cases, putrefaction will be found to begin early, 
and the changes in the blood and the gross changes in the other 
organs will, for the most part, remind one of sepsis rather than of 
anthrax. 



126 SURGICAL DISEASES. 

Prognosis. — Prognosis for man is not usually unfavorable, the 
majority of cases recovering with more or less local destruction of tis- 
sue. Should, however, infection become generalized, the case will prob- 
ably terminate fatally. 

Treatment. — This must be both local and constitutional. The 
former should consist of the most radical possible attack, and should 
include complete excision of the infected area, with the use of active 
caustics or the actual cautery. In fact, the latter instrument offers a 
most valuable means for combating the destructive tendency of the dis- 
ease. Sloughing and separation of the cauterized mass may be hastened 
by warm antiseptic poultices. Subcutaneous injections of 5 per cent, 
carbolic solution have been practised with apparent benefit in a number 
of cases, but should only be relied upon in the treatment of the milder 
manifestations. 

Benefit will accrue from the use of the ichythol-mercury ointment whose for- 
mula I have given when considering the treatment of Erysipelas. It has been 
suggested to treat these cases by the employment of the bacillus pyocyaneus, since 
it is known that this organism when injected with the anthrax bacillus materially 
attenuates its effect. 

Malignant CEdema. 

This disease has been recognized for some time, mainly by French 
and Continental clinicians, and under such names as gangrene foudroy- 
ante, gangrene gazeuse, gangrenous septicaemia, and gangrenous em- 
physema. The name malignant oedema was given by Koch, who 
identified the infectious organism. It is one of the most dangerous 
forms of gangrenous inflammation, and occurs sometimes after serious 
injuries, and, again, after most trifling lesions, such as those inflicted by 
the dirty pointed instruments of the gardener, etc., or even the stings of 
insects. Two cases are on record where the disease followed a puncture 
of the hypodermic needle for the administration of morphine. In one 
of these the organism was found in the solution ; in the other it prob- 
ably had been deposited upon the skin. 

Malignant oedema is essentially a specific form of gangrene (see 
Chapter A T .), and is mentioned here rather because of its specific cha- 
racter. It is characterized by rapidity of spread and the specific nature 
of the exudate, as well as by the speedy destruction of the tissue in- 
volved, and by more or less gas-formation. It is not the same as the 
gaseous phlegmons described by some German surgeons, yet partakes of 
their general character. (Gas phlegmons have been rarely noted, their 
peculiarity being formation not only of pus, but of more or less offensive 
gases, which escape when the plegmon is incised. The gases are due 
to the presence of saprophytic organisms, and gas phlegmons, as such, 
are to be regarded as instances of mixed infection.) 

Malignant oedema is known by the brownish discoloration of the overlying skin, 
which is streaked with blue where the overfilled veins show through it, while the 
underlying tissues are sodden with fluid and more or less blown up by the gaseous 
products of decomposition, so that the finger detects a firm crepitus, as is common 
in subcutaneous emphysema. From the wound, if one there be, flows a thin, foul- 
smelling secretion, which may also be expressed from the deeper layers. That the 
neighboring lymph-spaces and nodes are actively involved is evident from the 
enormous swelling of the latter, as well as from the general condition of the 
patient. The rapid elevation of temperature with but trifling remissions remains 



DISEASES COMMON TO MAN AND ANIMALS. 127 

constant until shortly before death. The tongue early becomes dry and cleaves to 
the palate, its surface being covered with a thick, foul fur. Patients early become 
apathetic, complaining only of pain and burning thirst. Delirium and coma 
usually precede death, which may occur in even so short a time as fifteen to thirty 
hours. After death the cadaver bloats quickly and putrefaction goes on with 
amazing rapidity. 

Post-mortem Appearances. — At the seat of the lesion even mus- 
cles and tendons will be found macerated, bone denuded and surrounded 
by a putrid fluid, the entire region presenting a notable swelling and 
infiltration of soft parts with reddish fluids and stinking gases. The 
overlying skin will be stretched, and superficial blisters may deepen the 
intensity of the process. The veins are clogged with decomposed blood 
and broken-down thrombi, and in the heart and large vessels will be 
found putrid liquid as well as gas, to whose presence early and sudden 
death is probably due. 

Prognosis. — This, for the most part, is bad, especially when the bacil- 
lus of malignant oedema is alone at fault. Patients may escape with their 
lives, but always at the expense of more or less tissue-destruction. 

Treatment. — This must consist of extensive incision to permit 
escape of fluids and gases and relieve tension ; of such antiseptic appli- 
cations as can be made available ; of immersion of the affected part in 
a hot antiseptic bath, if this be possible ; and of such vigorous stimu- 
lation by the most powerful measures — strychnia, alcohol, etc. — as may 
be possible, in order to support the patient through the period of pro- 
found depression characteristic of the disease. 

Actinomycosis. 

This also is a subacute, but always destructive infection by a specific 
micro-organism, though not a bacterium. Known always as actinomy- 
cosis in man, the disease, which is most common in cattle, has been 
known commonly as lumpy jaw or swelled head, and years ago was 
usually regarded as cancer or as a malignant affection. 

Many old museum specimens labelled as cancer of the tongue, jaw, etc. have 
of late been shown to be instances of actinomycosis of these parts. It is occasion- 
ally met with in man, so that now there are probably at least three hundred cases 
on record in this country and in Europe. The organism was recognized some fifty 
years ago by Langenbeck and Lebert, but was not scientifically described until 
thirty years later. The names of Bollinger, Israel, and Ponfick will always be 
connected with these researches. 

The organism itself belongs among the ray fungi, is known as the 
actinomyeis, and occupies a somewhat uncertain place in classification. 
It is large enough, when entire, to be noted by the naked eye, has ordi- 
narily a yellowish tint, a tallowy consistence, and may be seen under 
the microscope to consist of a cluster of branching prolongations, club- 
shaped at the end, radiating from a common centre. They give it rudely 
a sunflower appearance. It is stained with difficulty, best with a com- 
bination of picrocarmine and some aniline dye. In tissue-sections ihe 
Gram stain is the best. It is cultivated with difficulty, but can be 
grown upon solid media and may be inoculated. 

As met with in tissue or in pus these fungi constitute small granula- 
tions, giving usually a gritty sensation to the finger, which is due to the 
presence of calcium salts. The recognition of this calcareous material 



128 



SURGICAL DISEASES. 



is of great importance, since it may enable a diagnosis to be made off- 
hand which otherwise might puzzle one. In the only case so far met 
with by the author the diagnosis was established within a minute by the 
detection of these little particles. 

The disease is very common among cattle in certain regions, and causes 
the candemnation of many animals in every large stockyard establishment 
where inspection is careful and scientific. It occurs oftener in young than 
in old animals, and most often in those which come from valley regions and 
marshes. In animals infection occurs almost invariably through the mouth, which 
Fig. 23. Fig. 24. 





Actinomycosis bovis, from sections of a " lumpy 
jaw," showing ray fungus (Crookshank). 



Actinomycis, from lirer of a male natient : 
a, rays of fungus ( T ' 5 oil immersion). 



is easily explained by the fact that in grazing the lips, tongue, and gums are likely 
to be irritated and infected at any time from soil containing these fungi along with 
growing grain. The path of infection, then, is usually by the mouth, while acci- 
dent seems to determine whether the infection shall manifest itself mainly in the 
intestinal canal or the respiratory tract. In animals there is less tendency to sup- 
puration than in man, the infection in man being usually a mixed one. The name 
lumpy jaw, so generally given to the affection, is indicative of the most conspicu- 
ous lesion in cattle, for the organism, having once invaded the gum, for instance, 
passes quickly to the bone, or, having involved the tongue, is not slow to infect 
the lymphatics of that region. In consequence we have tumors, often of inordinate 
size, which may involve the bones or the soft parts and cause great disfigurement, 
along with necrosis, leading eventually to the death of the animal. These tumors 
are essentially granulation-tumors due to the presence of a specific irritant — namely, 
the actinomycis — which acts here as do the tubercle bacillus, the lepra bacillus, 
etc. in other infectious granulomata. 

In man the disease is almost always accompanied by abscess-forma- 
tion, the pus containing the distinctive yellow gritty particles which are 
found in no other disease. The strong resemblance between the lymphoid 
cells of this form of granuloma and the embryonal cells of sarcoma has 
permitted the perpetuation, until recently, of confusion between these two 
neoplasms. 

Large abscesses form as the result of the coalescence of small ones, 
and by the time the disease is recognized extensive destruction and loss 
of substance may have taken place. In man it is not alone about the 
mouth that the disease is noted, although primary lesion here is bv no 
means infrequent. It leads to affections similar to that already spoken 



DISEASES COMMON TO MAN AND ANIMALS. 



129 



Fig. 25. 



of in cattle, with a progressive infiltration and breaking down, including 
actual necrosis of bone, etc. The pus will escape at various points, 
and may give to the surface an appearance as of many craters with a 
central cause. When the disease has involved the lung, either directly 
or indirectly, the fungi and the calcareous particles may be found 
in the sputum. Should there be suspicion of this involvement, the 
sputum should always be examined. Even in the heart-substance 
tumors of this same character have been found. The first case noted 
in man had undergone extensive vertebral caries. Intestinal infection 
is possible, in which case multiple lesions will form in the intestinal 
walls, which may contract adhesions to the abdominal parietes and dis- 
charge externally through them. The appendix has been found involved 
in such lesions. Infection of the skin has also been described, though 
this occurs more rarely. 

Diagnosis. — Actinomycotic lesions have been in time past mistaken 
for cancer, sarcoma, tuberculosis, syphilis, etc. Without going more 
minutely into differences, it is enough 
to say that in man it will always be 
characterized by more or less sup- 
puration, and that in the purulent 
discharge from the infected focus the I 
characteristic yellow calcareous par- 1 
tides should enable recognition of 
this disease at once. 

Prognosis. — So long as the focus j 
is accessible it is a purely local I 
matter, and prognosis is as favorable 
as in local tuberculosis ; but, inas- 
much as in too many cases infection I 
has proceeded to a point where the 
surgeon cannot safely follow it, prog- 
nosis must be guarded. Actinomy- 
cosis is free from acute manifestations, 
for the most part free from pain, pur- 
sues a chronic course, and is charac- 
terized, as are the other slow infec- 
tions, by progressive emaciation, 
prostration, etc. Inasmuch as it is 
essentially a chronic condition, time 
is afforded for careful study in doubt- 
ful cases, for microscopic examination, etc. 

Treatment. — This must consist of radical extirpation of all infected 
tissues and areas. If this can be done thoroughly, and safely in other 
respects, one may hold out a prospect of positive cure. Free incision, 
wide dissection, the use of the actual cautery, etc. are always called 
for in these cases. If it involve the tongue alone, for instance, there 
is an excellent prospect; if but a portion of the jaw be involved, 
a complete excision of one-half or more may be followed by excellent 
results. If, however, the lung, liver, vertebrae, or other vital and inac- 
cessible parts be involved, surgical measures may afford amelioration,, 
but can hardly be expected to cure. 




Actinomycosis in man (Musser). 



CHAPTER IX. 

SURGICAL DISEASES COMMON TO MAN AND THE DOMESTIC 

ANIMALS (Continued). 

By Roswell Park, M. D. 



Tuberculosis. 



The most important and frequent of the infectious diseases common 
to animals and man is tuberculosis. This is, for the most part, a sub- 
acute or chronic affection, although in a small proportion of cases it 
assumes an acuteness of type which may make it fatal within so short a 
time as fourteen or fifteen days from the first recognizable symptom or 
even less. Tuberculosis as a form of disease is more prevalent than 
any other, and is the cause of death of a proportion variously estimated 
at from 20 to 30 per cent, of mankind. It is a disease which intimately 
concerns the surgeon, perhaps even more than the physician, inasmuch 
as it is also the most common of all the so-called surgical diseases. The 
frequency with which it is met varies in different parts of the country, 
and~ in some measure with the character of the population. In the 
average surgical clinic of the United States probably 25 per cent, of 
cases of surgical disease are manifestations of this affection. 




Synovial membrane with tubercles ; X 70 : giant-cell in the middle of a sharply outlined tubercle- 
about it round-cell infiltration (Krause). ' 

Surgical tuberculosis now covers the entire range of disease-manifestations 
formerly inaccurately and inaptly described as scrofula. The term scrofula is now 
130 



DISEASES COMMON TO MAN AND ANIMALS. 



131 



Fig. 27. 



expurgated from medical terminology, and there is no longer any excuse for its 
continuance, save possibly in making certain explanations to the laity, who are 
not yet educated to the new term. All of the active manifestations formerly 
regarded as scrofulous are now known to be due to tuberculosis. 

To the presence of tubercle bacilli in the tissues is due that distinctive 
aggregation of cells which constitutes the so-called miliary tubercle. 
Its presence and arrangement are apparently the direct outcome of the 
irritation produced by these minute foreign bodies, and its method of 
grouping is so characteristic that it may be everywhere and usually 
easily recognized. Its centre is composed of one, possibly several, giant 
celh, whose nuclei are usually arranged 
around the margin, with perhaps de- 
generative changes going on in the 
interior of the cell itself. In this 
giant cell, as well as outside of it, 
may be seen one or several tubercle 
bacilli. Around this centre are clus- 
tered a number of large cells, known 
as epithelioid, which may also contain 
bacilli. These cells are probably de- 
rived from epithelium when at hand, 
or from the endothelium of the vessel- 
walls, or from the fixed tissue-cells. 
Outside of this are yet other, usually 
spindle-shaped, cells, contained in a 
connective-tissue network and re- 
garded usually as lymphoid cells. 
When tubercle is experimentally pro- 
duced the bacilli seem more numerous 
than they do in instances of spon- 
taneous disease. This little aggrega- 
tion of cells constitutes a mass which 
may be recognized by the naked eye 
— a minute, usually white point or 
nodule, which is known as a miliary 
tubercle. It is subject to any one of 
several changes to be presently con- 
sidered, and it is usually found in 
large numbers when present at all. 
The punctate appearance of miliary 
tuberculosis is perhaps best seen upon 
the cerebral membranes or the peri- 
toneum in cases of acute miliary 
tuberculosis. By coalescence of a 
number of these nodules larger tuber- 
cles are formed, and by combination of coalescence and caseous degen- 
eration are produced the large cheesy masses which our forefathers called 
yellow tubercle. 

The epithelioid cells are by some regarded as modified leucocytes ; by yet others, 
as the product of division of the fixed cells. The giant cell is probably the result 
of irritation in one of these cells, the stimulus being sufficient to provoke division 




Tuberculosis of serous membranes [tunica 
vaginalis testis] ; round-cell infiltration 
(Goldmann). 



132 SURGICAL DISEASES. 

of the nucleus, but not of the entire cell. Since the principal cellular activity- 
occurs in the interior of this nodule, the result is a condensation about the periph- 
ery which furnishes eventually a sort of capsule, as it were, the tissues being hard- 
ened and condensed as if for this special purpose. The effect of this is to interfere 
with vascular supply, and finally to shut it off completely. So long, now, as no 
pyogenic infection occur, the original tubercle may gradually shrivel down and 
disappear, or, most likely, caseous degeneration will occur, and it may persist as a 
cheesy nodule for an indefinite length of time. As such a tubercle grows old the 
cells lose their identity, refuse to take stains, and a slow or quiet coagulation- 
necrosis results. In this nest sometimes calcium salts are precipitated, the result 
being a calcareous nodule. On the other hand, during the active stage of this 
tubercle-formation cell-resistance may be lowered, either from general or constitu- 
tional causes ; the original focus disintegrates ; tubercle bacilli are liberated, and 
are now carried hither or thither, metastatic tubercles being the result of their 
dissemination. 

Spontaneous healing of tubercle is possible, and may be due to three 
different causes : 

(a) Necrosis and exfoliation of diseased tissue (e. g. in lupus) ; 

(b) Cicatricial formation ; 

(c) Retrograde metamorphosis. 

Looked at from another point of view, the possible fates awaiting the 
miliary tubercle are the following : 
(a) Absorption; 
(6) Encapsulation; 
(e) Cheesy Degeneration ; 

(d) Calcareous Degeneration ; 

(e) Suppuration. 

Absorption of tubercle undoubtedly is possible under favorable 
circumstances, but just what constitute these favoring circumstances no 
one knows, since they occur in cases which do not terminate fatally. 
To be able to describe them would be to detail minutely the changes 
which permit of recovery after non-traumatic tubercular infection ; 
which clinical fact is amply demonstrated by the experience of the pro- 
fession. Absorption is probably largely a matter of phagocytosis. 

Encapsulation has already been spoken of, the capsule being formed 
by the condensation of the original cells of the tubercular agglomera- 
tion, the infectious organisms being thereby imprisoned so long that they 
are practically starved, and finally die. The tubercle bacilli, however, 
may long lie latent in such a cellular prison, and should anything occur 
to break the prison-wall, they may escape and still prove actively infec- 
tious. In this way are to be accounted for the fresh eruptions from old 
miliary or other deposits. 

Caseation is a condition more fully to be described in works on 
pathological anatomy. It comprises a series of changes in the chemical 
constitution of the cells by which an albuminoid mass much resembling 
casein in composition and appearance is produced. The English equiv- 
alent eheemj well describes many of these masses, which both cut and 
appear very much like domestic cheese. They have a yellowish color, 
and are met with in masses in size from a pin's head up to a robin's egg. 
These are the yellow tubercles of the older writers, and such a cheesy 
tumor has been called tyroma. 

Calcification refers to a peculiar deposition of calcium salts within 
the interior of these nodules, the first precipitation occurring usually in 
the centre of the giant cell, which is itself the topographical centre of 



DISEASES COMMON TO M AN AND ANIMALS. 133 



the miliary tubercle. As time goes on it may spread from this, until a 
mass easily recognizable by the naked eye and detectable by the finger 
is produced. Such calcareous particles are frequently found in sputa, 
and are always an index of the tuberculous character of the case. They 
differ markedly from the yellow calcareous nodules found in the pus of 
actinomycosis, and the only circumstances under which the) - are likely 
to be confused are met in pulmonary disease, which may prove to be 
either one or the other. 



Cold Abscess. 

Suppuration, as indicated, is the result, for the most part, of a mixed 
or secondary infection with pyogenic organisms. I have in the previous 
chapter grouped tubercle bacilli as among the facultative pyogenic bac- 
teria, yet I must say that, for the most part, pus is not formed in this 
disease except in consequence of coincident activity of other bacterial 
organisms. The matter of suppuration of tubercular foci is one of the 
greatest importance to the surgeon, because thereby is produced a dis- 
tinct class of so-called abscesses — namely, the cold or congestion abscesses. 
These, as usually coming under the surgeon's notice, are of the chronic 
type, and are free from almost all the ordinary signs of abscess-forma- 
tion. They are invariably the result of local infection, sometimes per- 
haps by the tubercle bacilli alone, but most often by combined action of 
these with pyogenic forms. For their formation a previous tubercular 
lesion is essential, and such is always met with. Wherever old tuber- 
cular lesions are met with, there may cold abscesses also form. No 
tissue or organ is exempt : they are found in the brain, in the bones, 
viscera, joints, skin, in fact everywhere. 

Cold abscesses have not only a significance of their own, but for the 
most part an identity. Their most distinguishing feature is a limiting 
membrane, which forms whenever sufficient time has elapsed. Much has 
been written about this in time past, and much error has been perpetu- 
ated with regard to it. This is the membrane formerly considered and 
called pyogenic, under the misapprehension that by it the pus or contents 
of the abscess were produced. I wish to emphasize in every possible 
way that this is a sad error. This membrane does not act to produce 
pus, but is rather the result of condensation of cells around the margin of 
the tubercular lesion, forming, as it were, a sanitary cordon for the abso- 
lute and definite purpose of protection against further ravages. I there- 
fore insist that the term pyogenic membrane be abolished, there being 
no such membrane under any circumstances, and that this be known as 
that which in effect it is — namely, a pyopfiylactic membrane. It is a 
protection against pus, and, were it not for its presence, there would be 
no limit to the spread of tubercular invasion. As it is, a lesion thus 
surrounded is shut off from most possibilities of harm, rarely encroaches, 
except by the most gradual processes, and, on the contrary, often con- 
tracts and reduces its dimensions, the watery portion of its contents being 
gradually absorbed and the more solid and cellular portions becoming 
condensed, finally, into matter which undergoes caseous degeneration, so 
that eventually recovery may ensue as the consequence of a metamor- 



134 SURGICAL DISEASES. 

pilosis of an original cold abscess into a caseous nodule surrounded by 
the old pyophylactic membrane, which is now serving as a capsule. 

The contents of the cold abscess are, in some instances at least, of rather acute 
origin, and consequently may have been originally pus or its near ally. Upon the 
other hand, in cases which have occurred very slowly this material never is, and 
never was, real pus, but is a semifluid debris having certain properties which 
remind one of pus. It has been my effort hitherto to devise for this material a 
name which should distinguish it from pus and indicate what it really is. Inas- 
much as most of it has been of a puruloid character, at least at one time, I have 
suggested that it be called archepyon (i. e. originally pus or puruloid). As this 
flows from such a cold abscess, it is more or less watery and contains caseous, some- 
times calcareous, nodules in masses of considerable size, and not infrequently 
sloughs of tissue and old shreds of white fibrous tissue which resist decomposition 
for a long time. This material has been thus imprisoned, sometimes for months or 
even years, and consequently has lost most of its resemblance to what it originally 
was. The organisms which first produced it have long since died out, and it is 
practically sterile. If any organisms survive, they are the tubercle bacilli, which 
are very much more resistant and tenacious of life than the ordinary pyogenic 
organisms. This is why most culture-experiments fail, and why even inoculation 
with the contents of an old cold abscess is often without effect even on most sus- 
ceptible animals. Nevertheless, the bacilli which the semifluid contents do not contain, 
may yet linger in the meshes of the pyophylactic membrane ; and here lurks the greatest 
danger in dealing with these lesions. 

In old cases the pyophylactic membrane is very tough and very 
adherent by its outer surface. It can sometimes be peeled off in strips 
of considerable extent, at other times cannot even be separated, or some- 
times is so placed as to render it impossible to follow it to its termina- 
tion. Complete extirpation of this membrane, or at least complete destruc- 
tion, is the duty of any one who attacks such a tubercular lesion ; and 
when its complete removal is impracticable, failure to remove it should 
be atoned for by some powerful caustic, such as zinc chloride, nitric acid, 
caustic pyrozone, or the actual cautery, which shall be made to follow it 
to its ultimate ramification. The membrane and the tissues underlying 
when thus cauterized will separate as sloughs, and these will be replaced 
by presumably healthy granulations, which should be encouraged until 
the original cavity be filled or the surface healed over. 

In a general way, then, it may be said that acute abscesses, as indi- 
cated in the previous chapter, have no real limiting membrane, although 
there is more or less condensation of tissues about the focus of infec- 
tion. A typical membrane is distinctive of tubercular abscesses, and is 
to be regarded always as their natural protection and a barrier against 
their further encroachment — nevertheless, a membrane whose inner sur- 
face may harbor still active organisms, which yet cannot escape throuo-h 
its outer texture. Consequently, to simply incise it or inefficiently scrape 
it is to do a worse than useless thing ; and one should never attack it 
unless he is prepared to thoroughly extirpate it or destroy its integrity, 
and in this way finally dispose of it. 

Cold abscesses, when near the surface, cause a bluish or dusky dis- 
coloration of the overlying skin, while the superficial and subcutaneous 
veins of this region are usually enlarged. Fluctuation is also a promi- 
nent phenomenon in connection with them when they can be palpated. 
Deep collections of this kind may be mistaken for cvsts or tumors, in 
which ca^e the aspirator needle may be used to facilitate diagnosis. They 
vary in size from the smallest possible collection of fluid to abscesses 
which may contain a gallon or more of puruloid material or archepvon. 



DISEASES COMMON TO MAN AND ANIMALS. 135 

They are known often as gravitation-abscesses, because by the mere weight 
of the contained fluid they tend to elongate or spread themselves in the 
direction in which gravity would naturally carry a collection of fluid. 
Thus, cold abscesses originating from tubercular disease of the lower 
spine frequently work their way along the psoas muscle and present 
below Poupart's ligament as psoas abscesses, or elsewhere about the 
thigh, while those which come from similar disease of the uppermost 
cervical vertebrae may present behind the pharynx, as the so-called 
retropharyngeal abscesses; and those from the dorsal spine present not 
infrequently as lumbar abscesses. These are but two or three familiar 
examples of what may occur in any part of the body. 

Treatment. — Aside from the treatment of cold abscesses, already 
indicated, by radical measures, other means have been suggested, and 
particularly for the treatment of those in which such extreme measures 
are impracticable or simply impossible. It is sometimes efficacious to 
simply tap or remove by aspiration the contents of such a cavity. It 
may never refill, or but slowly, and after repeated tapping alone a very 
small percentage of such cases will subside into inactivity and the lesion 
be subdued, if not absolutely cured. Of late treatment by injection of 
solutions or emulsions of iodoform has been quite generally accepted. 

This is based upon the alleged specific properties of iodoform as being pecu- 
liarly fatal to tubercle bacilli, presumably by liberation of free iodine. A cavity 
to be thus treated should be first emptied as completely as possible, after which 
may be thrown into it a glycerin emulsion or an ethereal solution, or a suspension 
in sterilized oil of iodoform, usually in strength of 5 to 10 per cent. From 25 to 
200 c. c. of some such preparation is introduced, while the walls of the abscess are 
more or less manipulated in the endeavor to completely disseminate the mixture. 
The cannula through which it has been introduced is then withdrawn ; and this 
can usually be done without any, or at most with but little, unpleasant iodoform 
effects. This is due to the prophylactic membrane, which limits the activity of the 
iodoform, as it has done that of the previous contents of the abscess. Such cavities 
have also been treated by washing out through a trocar with an injection of various 
antiseptic or stimulating solutions, among which we may mention hydrogen per- 
oxide, weak iodine solutions, etc. My own advice is to treat all tuberculous lesions 
radically when such measures are not contraindicated by their multiplicity or by 
too great depression of the patient, and so long as lesions are accessible to ordinary 
operative procedures. This same advice pertains also to those which have already 
spontaneously evacuated themselves or where the overlying skin is threatening to 
break and permit escape of contents. Almost any case where this is imminent is 
one in which the surgeon, as such, ought to interfere. On the other hand, in deep 
collections and in debilitated individuals the treatment by injection may at least be 
tried. 

With added years of experience my conviction has grown, however, 
that the best way in which to treat accessible tubercular lesions is by the 
most radical and merciless extirpation, and that, while this subjects 
patients to operative ordeals, it nevertheless shortens the period of time 
during which they are under treatment, hastens convalescence, and leads 
to very much more permanent results. 

The Gummata op Tuberculosis. 

The other and essential characteristic of tubercular disease, by which 
it manifests itself in surgical lesions at least, is the infectious granu- 
loma to which it gives rise. This is a term first applied by Virchow to 
new formations of granulation-tissue, which are the result of the presence 
of an invading and specific irritant. This tissue varies little in type, if 



136 SURGICAL DISEASES. 

at all, from that already described when dealing with the healing of 
ulcers, and is common to the neoplasms which are met with in tubercu- 
losis, syphilis, leprosy, glanders, and some of the other local infections. 
So little does the tissue-type vary in these different instances that it is 
difficult, if not impossible, to distinguish by microscopic sections of the 
unstained tissues, or at least those unstained for bacteria, to which class 
of lesions they belong. The production of granulation-tissue is, how- 
ever, of such general prevalence and such important significance that it 
must be spoken of at some length in this place. 

This tissue may be met with in any of the tissues of the body, but is seen per- 
haps least often upon the serous membranes of the cranial and peritoneal cavities, 
whereas in the joint-cavities it is common. It is provoked, as just stated, by the 
presence of tubercle, and has the power of penetration into and substitution for 
almost all the other tissues of the body. Thus in a primary tubercular focus within 
the bone a granuloma will form and extend its limits, while the surrounding bony 
tissue melts away before it; and it is by the growth of this tissue in a particular 
direction that tubercular products from within the bone-cavity are finally carried 
to the surface. When this material has escaped from bone or from tissues without 
the bone toward the surface, its presence is marked by induration, by livid dis- 
coloration of a limited area of skin, with elevation of the surface, which finally 
breaks down and shows discolored, bleeding, and pouting granulations, which in 
the absence of restraint now proliferate more rapidly, and often to the point where 
they get away from their own blood-supply, and consequently necrose upon the 
surface. This is the fungous granulation-tissue, especially of the German writers, 
and may be met with upon the surface, or is frequently seen in opening into joint- 
cavities and other tissues infected by tubercle. The appearances of this fungous 
tissue are modified somewhat by environment and pressure: in joints flat and 
radiating, masses of it will be found, extending along the synovial surfaces and 
into the articular crevices. This fungous tissue may grow in any direction, but 
apparently always does advance in the direction of least resistance. It leads to 
complete perforations of the flat bones, like those of the skull, while tuberculous 
masses from the dura may cause multiple perforations, the granulation-tissue finally 
escaping through the overlying skin. In tuberculosis of synovial sheaths and 
bursae it extends along, and may completely fill and even. distend, them. It will 
separate tissues which are united together, and it may lead to disintegration and 
disorganization of the firmest textures in the body. So long as it be not exposed 
to the air nor to pyogenic infection it will preserve its characteristics for a con- 
siderable length of time. Immediately upon exposure it is likely to break down, 
and infection will travel speedily along it into the deeper cavity whence it has 
sprung. A mass of this tissue contained within the normal tissues, condensed 
more or less by pressure, uninfected, and not freely supplied with blood, is entitled 
to the name of tuberculous gumma, whose tendency, however, is for the most 
part to break down and suppurate. Such gummata may be found in any part of 
the body, and differ only in unessential respects from the diffused and more or less 
infiltrated masses of granulation-tissue which occupy serous cavities or which 
extend in various directions. 

The lesions of surgical tuberculosis, except those already spoken of 
as constituting cold abscess, are so essentially connected with the presence 
of granulation-tissue, just described, or of this form of the infectious 
granulomata, that no student can appreciate the subject until he is quite 
familiar with this tissue in its various phases and "in various locations. 
Of such great importance is it that this be realized that some of the 
local manifestations of this new tissue must here be considered, although 
they may be rehearsed in other form in succeeding chapters. 

In the skin and subcutaneous tissues and in and under mucous 
membranes this granulation-tissue may be studied at places where it is 
free from most of the mechanical restraints to growth, and where in 
other respects its appearances are typical. The most characteristic 



DISEASES COM M ON TO MAN AND ANIMALS. 



137 



manifestations in the skin occur as lupus, a disease for a long time con- 
sidered cancerous or of uncertain etiology. We are in position now to 
teach, however, that lupus is always a cutaneous manifestation of this 
protean disease. 

In its incipient stages lupus consists of multiple minute nodules of granulation- 
tissue just beneath the surface, containing all the elements of true miliary tubercle, 



Fig. 28. 



Fig. 29. 





Lupus of hand, tubercular disease of bones, 
with absorption (Krause). 



Epithelioma developing upon lupus—" lupus- 
carcinoma " (Steinhauser). 



with infiltration of the surrounding skin, even into the subcutaneous fat. The 
most common location of these lesions is on exposed surfaces. Bacilli are not 
numerous, yet may be demonstrated in all these lesions. The tendency is more or 
less rapidly to break down, the result being a tubercular ulcer, which, as it extends, 
manifests usually a disposition to cicatrize in the centre while enlarging around 
its periphery. The dermatologists describe several different forms of lupus under 
the names hypertrophicus, vulgaris, maculosus, etc., all of which are essentially the 
same in character, the differences being largely constituted by the rapidity or slow- 
ness with which the granuloma of the skin breaks down. From the surface these 
growths mny extend and involve parts at considerable depth, even the periosteum. 
This name should also include the lesions described as scrofuloderma or scrofulous 
ulcers of the skin, they being all of the same real character. 

A variety known as anatomical tubercle has been described by numerous writers, 
found especially upon the hands of those who haunt dissecting-rooms or handle 
dead bodies, and is supposed to be the result of local inoculation. It appears 
usually as a warty growth, which ulcerates and becomes covered with a scab — is 
usually most indolent in character, but is followed by lymphatic involvement, and 
in rare instances by death from tubercular disease. 

In the lymphatic structures and lymph-nodes tuberculosis is a most 
frequent affection. In these localities it may occasionally be primary, 
but is almost always a secondary lesion. It is in separating from the 
lymph-stream the tubercle bacilli, which would otherwise be passed into 



138 



SURGICAL DISEASES. 



the general circulation, that the lymph-nodes, acting as filters, render us 
the greatest possible service. These filters, however, almost always 
become themselves infected, and, enlarging, they assume the appearances 



Fig. 30. 



Fig. 31. 




Tuberculosis of mesenteric lymph-node ; X 200 
(FrSnkel and Pfeiffer). 



Tuberculosis of cervical lymph-nodes 
(Holloway). 



known to the laity as scrofula, which in time past have been so generally 
spoken of as scrofulous glands. These lesions abound rather about the 
axilla and the cervical and bronchial nodes than about the lower extrem- 
ities. Nevertheless, the retroperitoneal, mesenteric, and inguinal nodes 
are occasionally infected. In these nodes will be found giant cells sur- 
rounded with epithelioid cells, containing bacilli and undergoing cheesy 
degeneration or suppuration. Infection often proceeds from centre to 
periphery, and then to the surrounding tissues, the filter, as such, having 
become so choked that nothing seems to pass it. By virtue of this sur- 
rounding infiltration (which used to be known as periadenitis, when 
lymph-nodes were spoken of as lymph-glands) generalized infection is in 
some measure prevented, while the natural barriers are altered and nat- 
ural distinctions between tissues are lost. This makes complete extirpa- 
tion of these tubercular foci often very difficult, while the adhesions 
which they contract, for instance, in the neck are often to the large vessels 
and nerve-sheaths, by all of which their operative treatment is naturally 
complicated. When infection from the superficial nodes extends toward 
the surface it is easily recognized by the dusky hue of the overlying 
skin, the hardness, infiltration, and, later, the fixation, of these masses, 
accompanied usually by evidences of suppuration. 

In the bones we find as often as anywhere expressions of tubercular 
disease. Strange to say, it is not much more than fifty years since 
Nelaton called attention to the frequency of these intraosseous lesions, 
and demonstrated the essentially tuberculous character of much that had 
hitherto been overlooked or considered under that vague term scrofula. 
. All those forms of bone disease comprehended under the names Pott's 
disease, spina ventosa, tumor albus, etc. are now known to be distinctly 



DISEASES COMMON TO MAN AND ANIMALS. 



139 



tubercular lesions. In many instances these follow the slight circulatory 
disturbances brought about by contusions, sprains, etc. This is espe- 
cially the case in those who are predisposed to this disease. 

Tuberculosis of bone always assumes the phase of miliary lesions, followed by 
the formation of a granuloma, which may gradually encroach upon surrounding 
tissues or may assume a more fulminating type and spread rapidly. Apparently 
because of the circulatory conditions, these lesions are most common near the 
epiphyseal lines of the long bones, seeking seemingly the ends of the bones, as 
pulmonary lesions seek the terminations of the lungs. These lesions may be 
solitary or multiple. Beginning always minutely, they spread so as to produce 
foci perhaps even two inches in diameter. As the result of the formation of 



Fig. 32. 




Tubercular spondylitis (caries) : a, osteogenesis and osteosclerosis ; c, cavity formed by degenera- 
tion of tubercular focus (Krause). 



granulation-tissue, the surrounding bone melts away and disappears, the result 
being a great weakening of its structure and expansion of its dimensions in order 
to make room for the growing mass within. The tendency of this granulation- 
tissue thus imprisoned is always to escape in the direction of least resistance. 
This carries it sometimes into the joint, sometimes out through epiphyseal junc- 
tions, and sometimes through channels in the bone made by its own pressure, with 
external escape and appearance of the dusky distinctive tissue, felt beneath and 
then upon the skin. Where bone is so weakened in one direction it is usually 
strengthened by compensatory deposition of calcium salts at other points, and the 
result frequently is a striking combination of odeoporosis in the immediate presence 
of the disease, with osteosclerosis, sometimes to a remarkable degree, even to eburna- 
tion, of an adjoining portion. When this mass undergoes caseous degeneration, the 
progress of the disease is much slower and the pain less. When it undergoes sup- 
puration, there are more evidences of inflammation, with more pain and systemic 
disturbance, as well as local swelling, tenderness, etc. The surrounding muscula- 
ture is rarely involved, although the periosteum is nearly always so. In fact, it is 
stated that in an inflamed and suppurating bone-lesion, if the muscles are exten- 



140 SURGICAL DISEASES. 

sively invaded, it maybe regarded as of syphilitic rather than of tubercular origin. 
The pijophylactic membrane already alluded to is seen in almost every instance of 
tubercular disease. The spina ventosa of old writers refers to the expansion of the 
shaft and medullary cavity of a long bone whose interior is occupied by a mass of 
tubercular gumma, which is perforated at one point, and through which opening 
it escapes as does lava from a crater to involve the structures on the outer side. 
The appearance of this granulation-tissue in joints as fungous tissue has already 
been alluded to. In a general way it preserves its fungoid characteristics until 
attacked by pyogenic or saprogenic organisms, when it quickly breaks down, form- 
ing an ulcer if upon the surface, or a cold abscess if not externally open. Tuber- 
cular disease of the bone is most common in the young, and in them the majority 
of tubercular joints are those whose bony structures have been first involved. In 
other words, the majority of cases of tubercular pyarthrosis are due to primary 
bone disease. As the result of the tubercular infection the bones become distorted, 
best illustrated in Pott's disease of the spine ; while, as the result of the constant 
irritation, joint-ends become displaced by chronic muscle-spasm, and joint-contours 
entirely altered by expansion of the affected bone and thickening and infiltration 
of the overlying soft parts. 

I have often, for the sake of illustration to medical students, drawn a certain 
analogy (following Savory) of the gross resemblances between lungs and bones in 
their behavior when involved in tubercular disease. In either case the structure 
is in a measure spongy and contains cavities and networks of tissue ; in each case 
the structures are invested by a resisting membrane — in the one instance, pleura, 
in the other, periosteum. Again, each is closely related to a serous cavity — the 
lungs to the pleural cavity, the bones to the serous cavities of the joints. Tuber- 
cular disease manifests a predilection for the extremities of both organs. Perfora- 
tion into the adjoining serous cavity is frequent, and previous to perforation col- 
lections of serous fluid are frequently noted — in the one instance pleurisy, in the 
other hydrarthrosis. Moreover, these fluids quickly or often become contaminated, 
and then become purulent, constituting empyema or pyarthrosis as the condition 
may be. One sees, too, in each place the same striking combinations of weaken- 
ing of tissue and strengthening in order to atone for the undermining of the disease. 
These are not all of the similarities that might be adduced, but are perhaps suffi- 
cient for the purpose of showing that tubercular disease is essentially one and the 
same thing, no matter what tissue be invaded. 

In the tendon-sheaths and bursse we frequently find manifestations 
of tuberculosis. When seen early these are always in the direction either 
of miliary affection or, most commonly, of tuberculous gumma, while 
when seen late the disease has usually advanced to the point of suppura- 
tion, and we now have cold abscess of the affected parts. 

In many joints and tendon-sheaths, particularly the latter, we find certain 
detached, usually colorless, firmly resistant masses, of smooth and polished sur- 
face, lying in a collection of fluid, in size from a minute particle up to that of a 
melon-seed. These have been known at various times as rice-grains, melon-seed 
bodies, corpora oryzoidea, etc., and for a long time their explanation was a mystery. 
It is now well established that in the majority of instances at least these are the 
result of fungous granulations which have become detached in small pieces, which 
then, in the absence of infection, have shrunken and become rounded and polished 
by attrition. The bursal enlargement and distention with fluid in which they 
are usually found is commonly spoken of as hygroma of that particular bursa. 
Tuberculosis of these bursse, however, does not always result so harmlessly as the 
formation of these bodies, but, on the contrary, tubercular infiltration may extend 
beyond the serous limits to the surrounding soft parts, with a tendency finally to 
external escape, just as in the case of bone-lesions. These constitute affections of 
the soft parts which are more or less destructive, and are always difficult, often im- 
possible, to deal with, because of the mutilation which a thorough extirpation of 
the disease would necessitate. 

In the testicles and ovaries, particularly in the former, tubercular 
disease is frequently met with. In the testicles it begins usually in the 
epididymis, forming a somewhat dense nodule and a distinct tumor 



DISEASES COMMON TO MAN AND ANIMALS. 141 

easily appreciated from the outside, although its minute character may 
be still concealed. The tendency here almost invariably is to progres- 
sive infiltration and breaking down, either into a caseous mass or, more 
commonly, into puruloid material, while sometimes acute infection 
supervenes. 

It is not always easy to distinguish between syphilis and tuberculosis of the 
testicle, though the latter is usually characterized by the same tendency to effusion 
into the adjoining serous cavity (i. e. that of the tunica vaginalis) as is manifested 
in disease of the lungs or bones. When the disease is extensive the overlying 
skin is involved, and frequently by the time the surgeon has to deal with these 
cases perforation and escape of fungoid tissue on the outside have occurred. 

In the kidneys, in the ureters, as also in the bladder, tubercular 
lesions are noted, the miliary form being particularly frequent in the 
former. Tubercular disease of the kidney leads sooner or later to casea- 




Gross appearance in tuberculosis of the mamma (Dubar). 

tion and a condition of pyonephrosis or its equivalent, which calls 
practically always for extirpation of the affected organ. Tubercle 
bacilli are sometimes recognized in the urine, but only when the lesion 
has an opportunity of discharging into one of the urinary passages. 

In the peritoneum tubercle appears usually in the miliary form, 
leading sometimes quite rapidly to such extensive involvement of, and 
interference with, visceral functions as to produce anasarca or more 
general disturbance prior to death. Acute miliary disease here is as 
rapid and as essentially fatal as the same affection of the dura or pia, 
while the more chronic forms are followed by degenerations that may 
involve the intestines either in agglutinated masses or in ulcerations 
and possible perforations. The indication in all tubercular lesions of 
serous membranes is for exposure by operation, disinfection of the sur- 
face, and evacuation of retained fluids. Recovery from tubercnlar per- 
itonitis, even of acute type, after abdominal section is now definitely 
established as a possibility. The same would probably be true of tuber- 
cular meningitis were we permitted to expose the membranes and attack 
them or drain them in the same way. 

Although a few distinct organs or tissues have here been specifically 
considered in their relations to tubercular disease, there is no organ nor 
tissue in the body which is exempt from its ravages and in which 
evidences of tubercular disease may not be found. Even the mammary 
gland occasionally presents tumors composed of tubercular granuloma 
which more or less simulate malignant disease, while, nevertheless, 
calling for the same radical treatment. (Vide Fig. 33.) 



142 SURGICAL DISEASES. 

Paths of Infection. — The tubercular virus may enter the body 
through various channels. Probably in the majority of instances it 
gains entrance through the respiratory tract, less often by the aliment- 
ary canal, and occasionally by air-contact of open wounds or direct infec- 
tion by local agencies. It is now well established that tubercular disease 
is not inherited, although a predisposition to its ravages certainly is 
transmitted from parents to children. 

In what this predisposition consists is not always easy to say. As the tubercle 
bacillus grows in the tissues, it is by preference an anaerobe, and it seems to be 
lowered in activity or banished by access of oxygen. It has been shown that in 
those individuals in whose pallid skin, long bones, flabby muscles, and pale con- 
junctivas we recognize a predisposition to this disease, the heart is disproportion- 
ately small as compared with the weight and size of the lungs. This means a 
relatively feeble pumping-power, and is perhaps the best explanation yet offered 
for what is everywhere accepted as a fact. The mucous membranes of the nose and 
throat are trie first lodging-places usually for germs carried by the air, these find- 
ing here the warmth and moisture necessary for their detention, development, and 
growth. So long as these membranes be unbroken and healthy, infection is rarely 
possible, but let tubercle bacilli become caught in the crypts of the tonsils or the 
adenoid tissue in the nasopharynx, and the other disturbance, set up by irritant 
organisms of various species, will usually bring about conditions favoring their 
growth and incorporation into the living tissues. This Iymphadenoid tissue, then, 
is as often as any the port of entry for these organisms. The explanation for 
local and surgical tuberculosis in bones and other accessible tissues probably is 
connected with causes determining at these points an area of least resistance in 
which the germs find tissues more susceptible than elsewhere, and in which they 
may live and thrive. 

Not the least interesting and important of the considerations regard- 
ing tubercular disease is the possibility of an acute outbreak of tubercu- 
losis after long latent or chronic manifestations of the disease. This 
means, in effect, the onset of general miliary tuberculosis which shall 
quickly terminate fatally, and death is not the infrequent result of such 
extremely rapid outbreaks from tubercular disease of joints, bones, 
ovaries, etc. For the disease when it has assumed this extremely rapid 
type there is, so far as we yet know, no help. 

Diagnosis. — So far as the general recognition of tubercular disease is 
concerned, it is not often difficult. It is accompanied usually by more 
or less marked cachexia (at least this is the case when infection is serious 
and widespread), one of whose principal characteristics is the so-called 
hectic (habitual) fever of old writers. This was a fever of a remittent type, 
accompanied also by more or less colliquative night-sweats, with dryness 
of the skin during the daytime, flushing of the face, etc. Hectic fever, 
as a matter of fact, often accompanies tubercular disease, but is seldom 
met with until pyogenic infection has occurred and suppuration is taking 
or has taken place. There is now much reason to consider hectic fever 
as an auto-intoxication from absorption of morbid products. In advanced 
cases we may find evidence of amyloid changes, although these are seldom 
recognized prior to autopsy. Altogether, it is seldom difficult to recog- 
nize tubercular disease except when at a considerable depth. Here, so 
long as there be no suppuration, there is little tendency to leucocytosis, 
by which diagnosis as between sarcoma and tubercular infection may per- 
haps be made. Sometimes when in doubt the exploring trocar or an 
exploratory incision may be resorted to, it being always best to be pre- 



DISEASES COMMON TO MAN AND ANIMALS. 143 

pared at the same time to proceed with whatever further operative pro- 
cedure the findings may indicate. 

Treatment. — It is well to emphasize, first of all, that tubercular 
disease when circumscribed and accessible is a distinctly curable affection. 
If this be once accepted, it puts a much more hopeful aspect upon the 
condition than it formerly bore. It moreover justifies operations of a 
much more radical nature than were formerly practised. Treatment 
should be divided into the hygienic and constitutional and the local and 
operative. 

Of all the natural remedies, oxygen undoubtedly ranks first. This means the 
best of ventilation, an outdoor life if possible, and preferably in localities and at 
altitudes free from dust and well supplied, with ozone. When this is impossible 
inhalations of dilute oxygen are capable of doing much good. The diet should 
be rich and nutritious, at the same time capable of complete digestion. The 
emunctories should be stimulated and elimination favored in every possible way. 
Undoubtedly the old standard remedies — cod-liver oil, compound syrup of hypo- 
phosphites, et al. — are beneficial, and much good may be accomplished by their 
proper use. 

Certain remedies have been at various times supposed to be endowed 
with specific properties, and for many years clinicians have endeavored 
to find that substance with which the system could be safely saturated 
which should yet prove inimical to the parasite causing this disease. 
Such agent has not yet been discovered ; nevertheless, much has been 
done in this direction. Of the remedies which to-day are lauded for 
this purpose, I will speak of two — namely, creosote and guaiacol. These 
are somewhat difficult of administration, but if the latter be given in the 
form of the carbonate, generally known as benzosol, it comes the nearest 
in my estimation to the ideal for which we are striving that has yet been 
discovered. Benzosol should be given to the adult in doses of at least a 
gram a day, perhaps more. It is much better tolerated and much less 
offensive than the guaiacol from which it is made. I have never seen 
anything but benefit result from its use, and yet would not laud it as by 
any means a positive cure. Nevertheless, in conjunction with other local 
and constitutional measures its administration may be followed by com- 
plete recovery. 

Of the various local measures, I would place first of all physiological 
rest, which can be achieved in some places better than in others. The 
various forms of apparatus resorted to by orthopaedists are simply 
mechanical measures in furtherance of this purpose. A number of 
surgeons have much faith in iodoform, used locally in solution or sus- 
pension in some menstruum like glycerin, oil, etc. The benefit which has 
been claimed in some cases is certainly not duplicated in the experience 
of all surgeons ; nevertheless, it has undoubtedly been of service. A 
recent and most promising method of treating tubercular disease of the 
extremities has been suggested by Bier, and consists in the establishment 
of a permanent hyperemia by the application of a rubber tourniquet on 
the proximal side of the lesion. 

It would appear that the access of more blood which is thus permitted is inim- 
ical, presumably by the presence of the oxygen which it brings, to the develop- 
ment of the disease-germ. The method depends for its rationale upon the fact that 
the congested lung does not become tubercular. Lannelongue has suggested what 
he calls the sclerogenic treatment of tubercular lesions, by injection of a very dilute 



144 SURGICAL DISEASES. 

solution of zinc chloride, which serves as an irritant and produces a tissue-sclerosis 
that serves the purpose of a prophylactic membrane, while at the same time the 
solution is fatal to those germs with which it comes in contact. This treatment 
is painful and has not found wide acceptance. 

The astute surgeon, who gains the confidence of his patients and 
retains it, will not hesitate to remove by a suitable operation that tuber- 
cular focus which he feels confident that he can reach and extirpate. 
The resulting tissue-defects may be in many instances atoned for by 
plastic operations. At other times this procedure means excision of some 
joint, which leaves usually a much better functionating member than 
would the disease if permitted to go on to spontaneous recovery — i. e. 
ankylosis — and at the same time removes a focus of disease which is a 
menace, if left, to the future welfare of the patient. It may mean at 
other times amputation, but the artificial limb-maker now supplies a 
member vastly more useful than a natural one crippled by this infec- 
tious disease. In a general way, then, time may be saved and recovery 
ensured by early and judicious operation, while later in the course of this 
protean malady it may be absolutely necessitated in the endeavor to save 
life. How much better, then, to operate early when less is required and 
when the future outlook is so good ! 

After operations where clean extirpation and reunion of the parts 
with primary healing is impossible, I recommend a local dressing of 
balsam of Peru containing 10 per cent, of guaiacol and 5 per cent, of iodo- 
form. Gauze saturated with this and packed into the cavity best accom- 
plishes the purposes of a surgical dressing for such cases. 

Deep pain of tubercular lesions, especially in bone, is often relieved 
by ignipuncture, meaning thereby a perforation into the depth even of 
the bone-marrow by the actual cautery (Paquelin's), which may be thrust 
directly through the skin or which may be used after exposing the bone 
by incision. The use of the actual cautery, by the way, is indicated in 
eradicating and destroying tubercular tissue when a neat dissection or 
extirpation is impossible. 

Tuberculin. — Finally, the treatment of tuberculosis cannot be dismissed with- 
out a reference to the glycerin extract made from a filtered culture of the tubercle 
bacillus, containing the peculiar toxalbumen first prepared by Koch, for ever asso- 
ciated with his name, and first given to the world in 1890, when its announcement 
created a perfect furore and aroused hopes that have never yet been, perhaps never 
may be, completely realized. Yet, in spite of disappointments which have often 
followed its use, I wish to state here my own convictions that it is a remedy of 
great value when judiciously used in selected cases. I have never faltered in 
moderate confidence in its efficiency, and have not ceased to use it since it was first 
introduced. To-day I believe that in almost any case of surgical tuberculosis, 
when properly used, it is capable of doing great 'good, but I would by no means 
rely upon it alone, but would use it as an adjuvant in the after-treatm'ent of ope- 
rative cases or as a remedy of prime importance in certain cases not adapted to 
operation. One should begin its use by doses of 1 milligramme, injected beneath 
the skin near the lesion two or three times a week, depending upon the reaction 
produced, increasing the dose gradually until even a decigramme may be given at 
once without undue reaction. The diagnostic value of the material must also not 
be forgotten, since by its use one may possibly decide in mooted cases as between 
tubercular or some other disease. Of the modifications of this remedy introduced 
by Klebs, Hunter, and others there is not time here to speak in detail. Undoubt- 
edly they all have virtues of a common character, and, so far as my own observa- 
tion is concerned, one has but little to choose as between them. 



CHAPTER X. 

SYPHILIS. 

By J. A. Fordyce, M. D. 



Synonyms. — Lues venerea ; Morbus gallicus ; Pox ; Verole, etc. 

Syphilis is a chronic, general infectious disease, acquired by direct con- 
tact with a lesion of the malady in another individual, through the medium 
of some infected object, or by inheritance. It is generally a venereal 
disease, though many exceptions to this rule exist. 

The infection pursues a somewhat regular though indefinite course, 
periods of activity alternating with periods of repose or latency. It 
begins with an initial sore, the point of entrance of the virus, after a 
period of incubation following exposure. In inherited syphilis no 
primary sore is present. The initial lesion is followed by a second 
period of incubation, during which time a slow, general infection of the 
body is taking place, characterized by lymphatic node-enlargement, pains 
in the joints and bones, usually worse at night, anaemia, fever, loss of 
strength, and by other symptoms indicating a progressive intoxication 
of the organism. 

Syphilis presents many points of similarity in its symptomatology and morbid 
anatomy to the chronic infective granulomata with which it is usually classed. In 
many of them the virus retains its activity for long periods of time, and in certain 
stages produces lesions which are local rather than general. Attention has also 
been called to the resemblance which exists between syphilis and the acute exan- 
themata, in that a definite period of incubation in all these diseases is followed by 
symptoms of general infection, with an outbreak on the skin and mucous mem- 
branes and transitory congestions of various organs and tissues. The acute erup- 
tive fevers and syphilis are alike in conferring a partial or complete immunity 
against subsequent attacks, and it is a noteworthy fact that the essential nature of 
the contagion of these affections has eluded our investigations. 

Stages op Syphilis. — Although not separated by well-defined 
limits, it is generally customary to divide syphilis into three stages or 
periods, which may be briefly defined as follows : 

Primary syphilis embraces that period of the disease which elapses 
from the moment of infection to the appearance of general symptoms, 
including the first incubation, the time from exposure to the appearance' 
of the initial sore, as well as the second period of incubation, the time 
following the primary lesion to the appearance on the skin of the charac- 
teristic exanthem. The first stage of syphilis, while varying in dura- 
tion from eight weeks to four or five months, is pretty regular in its 
evolution. 

The secondary stage, or secondary syphilis, includes for conve- 
nience of study and classification the early eruption on the skin and 
mucous membranes, as well as the accompanying disturbance of the 
general health and other phenomena which are peculiar to the time in 

10 145 



146 SURGICAL DISEASES. 

question. One type of eruption may be rapidly succeeded by another, 
or intervals of latency may occur between the successive outbreaks of 
the disease for a period of from one to three years, or longer, before the 
development of lesions which belong to the so-called tertiary stage. 
This period of syphilis, which is of exceptional occurrence and multi- 
form in its manifestations, is spoken of as the stage of gummatous for- 
mation, and includes the deeper-seated and destructive lesions of the 
skin and underlying tissues, visceral and bone affections, as well as other 
pathological changes which are directly or indirectly due to the specific 
virus. 

The early eruptions are usually superficial, of symmetrical distribu- 
tion, rapid in their development and course, while the later ones occur 
without order, are slower in their evolution, and show a greater tendency 
to undergo degenerative processes with destruction of the implicated 
tissues. 

In primary and secondary syphilis the disease can be conveyed by 
inoculation and heredity, while in the later stages it is exceptional for such 
transmission to take place. 

In whatever way syphilis manifests itself, the process is of an inflammatory 
nature, both in the initial lesion, the transitory eruptions on the skin, to the forma- 
tion of gummy tumors and interstitial connective-tissue growth in the late stages 
of the disease. The implication of the blood-vessels in the inflammatory process, 
leading to thickening- of their coats and partial or complete obliteration of their 
calibre, plays an important rSle in the pathology of the" syphilitic disease and its 
results. This blood-vessel inflammation is found in the initial lesion, the secondary 
eruptions, in gummatous tumors, and in connection with the chronic connective- 
tissue hyperplasia resulting directly from the irritant action of the specific virus 
or which occurs in organs which are or have been the seat of syphilitic new 
growths. 

Etiology. — Most of the chronic infective granulomata have been 
shown to depend on the presence of specific micro-organisms. As 
syphilis presents so many features in common with these affections, it is 
rational to suppose that it depends on a similar cause. The infectious 
character of the disease, its period of incubation, its gradual implication 
of the lymphatic system, the blood, and all the tissues of the body, 
clearly point to some infectious agent which multiplies in the system, 
and either directly or by virtue of its chemical products evokes the 
tissue-reaction and a general condition which constitute the morbid 
process. 

The facts that the lower animals are immune to syphilis and that cultivations 
from the infectious lesions yield no uniform or satisfactory results, render the 
study of its etiology one of great difficulty. The claims made regarding the pres- 
ence of micro-organisms in syphilitic lesions before modern bacteriological methods 
came into use are without value. In 1884, Lustgarten 1 claimed, by a special method 
of staining, to have found bacilli in the initial lesion, secondary papules, and in 
gummata, which closely resembled tubercle bacilli, but were thought to differ from 
the latter in their staining reaction. It has since been found that the tubercle 
bacilli cannot well be differentiated from the so-called syphilis bacilli by the 
method in question. 

Secondary Infection in Syphilis. — Pyogenic cocci have been found 
in syphilitic skin-eruptions, the bones, liver, and lungs of children who 
had died with hereditary syphilis (Kassowitz and Hochsinger). Kolisko, 

1 Wiener med. Wochenschrift, No. 47, 1884. 



SYPHILIS. 1 47 

Chotzen, and Doutrelepont made similar observations, and believed they 
gained entrance to the general circulation through the skin-lesions. 
While attributing to them no etiological importance in producing the 
disease, they yet thought the fatal issue in some cases of hereditary 
syphilis depended on septic processes brought about by such secondary 
infection. Their presence in the bones was believed to explain the sup- 
puration which is here sometimes met with in children with the disease. 
As the specific lesions in. acquired syphilis seldom suppurate, many 
modern writers believe that the exceptional occurrence of suppuration 
is determined not so much by the direct action of the virus of syphilis 
as by a secondary or mixed infection with pyogenic germs which gain 
access through solutions of continuity or are incited into activity by the^ 
diminished resisting power of the diseased tissues. 

The presence of pyogenic cocci in the deeper layers of the normal epidermis, as 
shown by Welch and others, renders the theory of the secondary infection of 
the specific lesions extremely probable. Gummata of the skin suppurate much 
more frequently than similar lesions of the internal organs, and pustular lesions 
in general are more frequent among the poorer classes of society who pay less 
attention to personal cleanliness. 

The character of the syphilides is altered by other forms of mixed 
infection, notably by a combination about the face and scalp with the 
seborrhoeal eczema of Unna. Finger, 1 in a very interesting and sug- 
gestive article, was the first syphilographer who endeavored to classify 
the symptoms which might be produced by the virus directly and those 
which presumably depended on its toxic product. The initial sore, as 
well as the lymph-node enlargement, he considers due to both the 
specific germ and its ptomaine. The latter, absorbed into the general 
circulation from an early date, confers the immunity which syphilitics 
present from an early period and long before the outbreak of the general 
eruption. The anosmia and other evidences of impairment of the 
general health are to be referred to a progressive intoxication from the 
chemical products which are being gradually absorbed into the general 
circulation. The secondary eruption, containing as it does the con- 
tagious element in a concentrated form, must be due to the bacillus 
alone or combined with its toxine. Tim hypothesis explains in a satis- 
factory manner the partial or complete immunity acquired by mothers who 
bear syphilitic children from the father with the latent disease, and other 
facts, which no other theory had attempted to do. 

Predisposing Causes — Aside from the virulency or attenuation 
of the virus which must be considered in explaining the severer and 
milder forms of infection, the resisting power of the individual upon 
whom the poison is inoculated plays an important role in the future 
development of the disease. The extremes of life — youth and old age — 
all conditions which impair the resisting power of the patient, as tuber- 
culosis, anaemia, malaria, alcoholism, etc., render it probable that the 
future course of the affection will be grave. Tuberculosis, while it 
renders the course of syphilis more severe, limits the free use of mer- 
cury, and thus deprives us of our most useful therapeutic agent. 
Syphilis sometimes renders a latent tuberculosis active ; tubercular 
abscesses of the lymph-nodes not infrequently occur during secondary 
1 Arehiv. f. Dermal, u. Syph., p. 331, 1890. 



148 SURGICAL DISEASES. 

syphilis in individuals who were apparently in robust health before 
their infection. Tuberculosis of the lungs has been precipitated by the 
presence of syphilis. 

Chronic alcoholism is an important factor in increasing the vulner- 
ability of the tissues to the specific poison. As both alcohol and syphilis 
have a predilection for the blood-vessels, their combined effects result 
in a more serious pathological condition. 

The Lesions and Secretions which Convey the Infection. — It 
is necessary for the syphilitic virus to come in direct contact with an 
abrasion of the skin or mucous membrane to convey the disease. This 
may occur directly or through the medium of some infected object. The 
initial lesion and all the early eruptions have been proven to be virulent 
by many observations, as well as by experimental inoculations. The 
secretion from condylomata lata, which are so frequently found on the 
female genitals, are believed by many to be the most frequent source of 
infection. Successful inoculations with the blood of patients during the 
early eruptive period have been made. It is not definitely established 
how long the blood retains its infective properties, but in the opinion of 
Finger and others it does not contain the virus during the latent stages 
of the disease — in the intervals between the periods of the eruptions. 

It is generally believed that the physiological secretions, milk, saliva, 
perspiration, tears, and urine from syphilitic subjects do not contain the 
virus or in such a diluted form that infection from them is not possible. 
As the micro-organisms of certain infectious diseases may pass through 
the glandular epithelium and appear in the saliva, milk, urine, etc., the 
possibility of transmitting the disease by such secretions is not abso- 
lutely excluded. The semen from syphilitic individuals cannot give rise 
to the disease by inoculation. The hereditary transmission of the dis- 
ease from the father to the child without a previous infection of the 
mother is well established. The infection of the ovum by the diseased 
spermatozoon is accomplished by a different, process from experimental 
inoculation. The mother may convey the disease to her child through 
an infected ovum, the father being healthy. It is generally conceded 
that pathological secretions not properly belonging to syphilis are not 
infectious unless mixed with the patient's blood or disintegrated portions 
of specific lesions. 

Gonorrhoea or chancroid may be contracted from a patient with syph- 
ilis, and yet no constitutional infection follow. When vaccinal lymph is 
taken from a syphilitic subject, syphiiis will not be conveyed unless 
there is an admixture of blood. Experimental inoculation made with 
the secretions of tertiary lesions have given negative results only. 
These results coincide with our every-day experience, which teaches us 
that the late lesions are, as a rule, neither inoculable nor transmitted by 
inheritance, and that such persons may be reinfected. As at one time 
the innocence of the secondary lesions of syphilis was affirmed, a wider 
experience may modify our view regarding the infectious character of 
the later ones. 

Modes of Infection.— The delicate mucous membrane of the gen. 
ital organs is easily abraded during sexual intercourse, and the absorp-, 
tion of the virus is thus facilitated. It is not difficult, therefore, to under- 
stand that over 90 per cent, of all primary sores occur on the genitals. 



SYPHILIS. 149 

In man the chancre is most frequently found on the inner side of the 
prepuce, its free edge, the glans, or sulcus coronarius. It is also met 
with on the skin of the penis, the scrotum, in the urethra, on the peri- 
neum, about the anus, etc. In women the labia, the tissues about the 
clitoris and urethra, and the fourchette are frequently its seat. It is 
found less often on the vaginal walls and the os uteri. Chancres on 
extragenital parts, as the lips, the tongue, the tonsils, the eyelids, and 
nipples, are not infrequently met with as the result of unnatural prac- 
tices. Chancres of the lips are found in 3 per cent, of all cases, many 
being acquired in an innocent manner. Wet-nurses are infected on the 
nipples by syphilitic children, multiple chancres sometimes resulting j 
children, too, are infected by wet-nurses with lesions on the nipples. 
Chancres on the face and fingers sometimes follow bites. Surgeons may 
acquire the disease on cuts or lesions of the hands when operating on 
patients with active syphilis. Accoucheurs and gynecologists are some- 
times infected on the fingers in vaginal examinations. Infants may be 
inoculated during parturition. These modes of infection are by direct 
contact. 

Mediate Contact. — The syphilitic poison may be conveyed by drink- 
ing vessels, eating utensils, or any articles used in common by members 
of a family or by individuals. In certain occupations, as where an im- 
plement like the blowpipe in glass-factories is passed from one person to 
another, infection has been produced. The disease has also been con- 
veyed by surgeons' instruments, dentists' instruments, etc. 

Vaccinal syphilis is now seldom encountered, as " humanized lymph " 
is not often employed. Syphilis may, however, be conveyed during vac- 
cination by the use of an infected instrument. 

The disease when acquired in an innocent — i. e. non-venereal way — is 
often spoken of as syphilid insontium. 

The Chancre. 

Synonyms. — Initial lesion ; Primary sore ; Syphilitic chancre ; 
Initial or Primary sclerosis ; the Hard or Infecting: chancre ; Hun- 
terian chancre, etc. 

The interval that elapses from exposure to the syphilitic virus to the 
appearance of the primary sore, or chancre, is called the first i ncubation- 
period. Experimental inoculation made on healthy persons showed that 
the minimum duration of this period was ten days ; the maximum, forty- 
two days ; its most frequent duration, from three to four weeks. After 
accidental inoculation clinical observation has shown the mean dura- 
tion to be about three weeks. It may exceptionally last seventy days 
or longer. 

Every case of syphilis, with the exception of the hereditary form, or 
syphilis conveyed from the infected foetus to the mother, begins with a 
primary lesion. It may be so slight and heal so rapidly as to escape 
observation, or in such a locality as not to be readily found. It must, 
however, have been present. It is seldom that an absolutely typical 
sore in its early stages comes under the observation of the surgeon. It 
is frequently complicated with other infections or its appearance has 
been changed by caustic applications. The classical sign, induration, 



150 SURGICAL DISEASES. 

may be wanting from a primary lesion which is followed by the consti- 
tutional disease, or it may exist in a purely local sore. Errors in diag- 
nosis are of frequent occurrence from placing too much diagnostic im- 
portance on a single feature. A typical chancroid may be converted 
into an indurated initial lesion, and instances of well-defined indurated 
sores have been observed without any constitutional disturbance. 

The initial lesion is usually single, unless several abraded spots are inoculated 
at the same time, or other eruptions, like herpes or the lesions of itch, are present 
where infection takes place. It is not at all unusual to see two or three chancres 
at the same time, and as many as a dozen have been observed to develop simul- 
taneously. Immunity to subsequent infection seems to take place very soon after 
a successful inoculation, although it is possible for a second infection to occur 
within a short time after the original one. 

Induration. — This one sign is almost pathognomonic of the chancre. 
It is present to some extent in the vast majority of cases. When well 
developed it extends beyond and beneath the limits of the superficial 
erosion or ulceration, and feels, when grasped between the thumb and 
fingers, like a piece of cartilage imbedded in the skin. Its firm and 
elastic consistency serves to distinguish it from other inflammatory 
infiltrations, while its boundaries are much better defined than in the 
chancroid.. The superficial variety gives to the finger the sensation of 
feeling a thin piece of cardboard or parchment beneath or in the skin. 

The development of the uncomplicated initial lesion is, as a rule, 
unattended by any subjective sensations, and frequently its possessor is 
ignorant of its existence. The ulceration or abrasion rapidly heals, but 
the specific induration passes away slowly and is of uncertain duration. 
It sometimes disappears within a few weeks after the secondary eruption, 
or in exceptional cases may last for six months or a year. It generally 
leaves no trace of its existence, but may terminate in a superficial pig- 
mented or pigmentless scar or spot or a keloid-like induration which 
gradually disappears. 

Varieties of Chancre. — After experimental inoculation on parts 
of the cutaneous surface removed from sources of irritation or infection 
it assumes the appearance of a dry scaling papule. A small patch of 
round or oval redness marks its beginning : this soon becomes more 
prominent and infiltrated, developing into a pea or bean-sized nodule, 
over which the epidermis may be slightly thickened. An abrasion may 
develop over the centre of the papule, giving exit to a serous discharge 
which dries as a thin crust. The papule may slowly disappear without 
ulceration, or become more infiltrated at the base and present a super- 
ficial ulcerated surface surrounded by a slightly elevated margin. The 
ulceration in this, as well as in other varieties of the initial lesion, takes 
place at the expense of the cell-infiltration rather than of the normal 
elements of the skin, being apparent rather than real, and healing with- 
out loss of the connective tissue of the derma. 

The Superficial Erosion. — This is the primitive lesion in the vast 
majority of chancres which are not preceded by the soft sore. When 
seen sufficiently early, it appears as a rounded, sharply-defined spot, of a 
dark-red color, from which the superficial epithelium has been detached, 
exposing a moist, smooth, or slightly granular surface. There mav be 
an insignificant central depression, but the edges of the erosion" are 
usually on a level with the surrounding skin. One or more such lesions 



SYPHILIS. 151 

may exist, which gradually develop an indurated base and heal more 
slowly than an ordinary excoriation or abrasion. The induration may 
be superficial and thin, assuming the parchment-like form, or extend 
deeper, giving rise to a distinct nodule. 

As the cell-infiltration in the initial lesion is in the main located 
about the blood-vessels, their anatomical distribution explains in part 
the varied outlines of the scleroses. The presence or absence of much 
loose connective tissue beneath the sore also moulds the outlines of the 
infiltration. 

The Hunterian chancre, or ulcerating initial lesion, is the most 
pronounced and well-developed form of the syphilitic sore. It orig- 
inates in an erosion or papule which increases slowly in size, is sharply 
circumscribed, of round or oval outline with a somewhat flattened top. 
With the increase in size its consistency becomes harder until it approx- 
imates that of cartilage. In color the new growth is brownish- or 
bluish-red. After a duration of ten or twelve days its epithelial cover- 
ing becomes macerated, giving rise to a serous discharge, or it becomes 
covered with a gray film. The centre of the infiltration undergoes 
a process of molecular disintegration ; its edges become elevated, so 
that an appearance of ulceration is presented which gives the impres- 
sion to the observer of a greater loss of tissue than is in reality the 
case. 

After three or four weeks' duration the Hunterian chancre begins to 
undergo a slow process of involution, which is hastened by the local and 
internal use of mercury. It heals without loss of tissue or with an 
insignificant scar. 

The Mixed Sore. — The subject of chancroid is considered in another 
part of this work (Chapter XLTVTII.). It is sufficient to state here 
that it is a local infectious ulcer, with a short period of incubation, almost 
exclusively met with on the genital organs. Infection with the virus 
of chancroid and syphilis may take place at the same time, the former 
passing through its stages of papule, pustule, and ulceration, with free 
suppuration. At the end of two or three weeks, the incubation-period 
of the syphilitic sore, the base and edges of the chancroid assume a 
characteristic induration and a brown-red color ; granulations spring up 
and the secretion of pus becomes less. Within a few days the local 
infectious ulcer is converted into a typical sclerosis which pursues the 
ordinary course of the latter. The syphilitic infection may, of course, 
follow that of the chancroid, but usually is simultaneous. 

Complications or the Chancre. — Local pyogenic infection is 
responsible for an extensive ulceration or suppuration of the primary 
sore. At times the inflammatory process may be so intense that the 
parts become much swollen and painful. When the preputial opening 
is narrow the occurrence of a chancre on its inner surface or in the 
sulcus coronarius often leads to complete phimosis or paraphimosis. 
The retention of the secretion from the sore in the preputial sac mace- 
rates the epithelium of the glans, producing an intense balanoposthitis, 
the discharge from which may simulate a gonorrhoea. Under such con- 
ditions the entire penis may become red, painful, and swollen. A 
neglect at this time to relieve the tension by a dorsal incision of the 
prepuce may result in superficial or deep gangrene, with partial or com- 



152 SVROICAL DISEASES. 

plete destruction of the glans, and possibly urethral fistulse or other 
complications. 

Extragenital Chancres. — Certain peculiarities are. presented at 
times by chancres of the general integument or mucous membranes at 
a distance from the genital organs. A chancre at the margin or bed of 
the nail seldom shows marked induration ; exuberant granulations are 
sometimes seen, and frequently suppuration is profuse. On the cheek 
or chin, where the tissues are lax, it attains a large size. It may ulcer- 
ate and be covered by crusts, and has been mistaken for malignant dis- 
ease. A tonsil which is the seat of a chancre enlarges, generally ulcer- 
ates, and at times is covered by a pseudo-membrane simulating the 
diphtheritic membrane. Enlargements of the submaxillary and cervi- 
cal lymph-nodes are simultaneously present. Difficult deglutition is 
often experienced. Chancres on the lip are commonly indurated, and 
sometimes present well-marked ulceration with a dark-red granulating 
surface (Plate V. Fig. 3). 

Enlargement of the Communicating Lymph-vessels and Nodes. 
— After the appearance of the initial sore, the next manifestation of the 
specific infection is in the lymph-nodes in anatomical communication 
with the lesion. Exceptionally, one or more lymph-vessels or thick- 
ened veins may be felt. as firm, hard, painless cords extending along the 
dorsum of the penis to its root. At times nodules form in the course 
of these thickened vessels, which undergo spontaneous involution or 
ulcerate. 

Diagnosis of the Initial Lesion. — Chancroids are practically 
always found on the genitals. They are generally multiple, have a 
short period of incubation, and begin as a pustule or small ulcer sur- 
rounded by a red areola ; a pseuds-induration may result from cctmtic 
or other applications. The floor of a chancroidal ulcer is irregular, 
covered by a grayish membrane ; its edges are frequently undermined, 
and it secretes pus freely. Chancroidal pus is auto-inoculable, both on 
the genitals and general integument. A single or double bubo, with a 
marked tendency to suppurate, is found in about 25 per cent, of cases 
of chancroid. It must be borne in mind that a chancroid frequently 
assumes an induration as the result of a double infection, and that the 
initial lesion of syphilis, from local infection or irritating applications, 
ulcerates and secretes pus. 

Herpes of the genitals occurs as a grouped vesicular eruption which seldom 
lasts longer than a few days. A history of former attacks is of aid in diagnosis. 
Cauterization of such lesions with carholic or nitric acid may obscure their normal 
features and cause them to simulate chancres or chancroids. 

A chancre of the lips or genitals has been mistaken for an epithelioma. The 
latter occurs later in life, is slower in its evolution, and does not implicate the 
lymph-nodes as soon as the initial lesion. 

A late lesion ef syphilis is sometimes found at the site of the original chancre 
or elsewhere, which has been mistaken for a primary sore. The serpiginous exten- 
sion or central ulceration, as well as the absence of the primary lymphatic involve- 
ment, would serve to distinguish it from primary syphilis. 

Pathological Anatomy of the Chancre.— The blood-vessels, 
including both the arteries and veins, show marked changes in the earliest 
stages of the development of the initial lesion. They are surrounded 
by large numbers of single, nucleated polyhedral cells, which are believed 



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SYPHILIS. 153 

by Unna to represent proliferating connective-tissue cells (" plasma- 
cells"). Few multinucleated leucocytes are seen. The endothelial 
cells of the vessels multiply, as shown by numerous mitoses and thick- 
ening of their intima ; the middle and outer coats are also thickened 
and infiltrated by leucocytes. As a consequence of the involvement of 
the vessels' walls and from outside pressure their calibre is encroached 
upon and frequently found to be obliterated. 

A section through a chancre, at the height of its development, reveals a 
dense cell-mass in the papillary and subpapillary region of the derma, which 
is pretty sharply defined on all sides, the blood-vessels lying for some distance 
outside of the infiltration are surrounded by the cells previously mentioned and 
present thickened walls. The epidermis at the edge of the induration in many 
cases is hypertrophied, the interpapillary process extending for some distance into 
the cutis. Leucocytes are also to be found between the cells of the epidermis, 
which is in part or wholly destroyed over the centre of the sclerosis. When the 
sclerosis is uncomplicated by a secondary infection, remains of the epidermis can 
frequently be seen over the central erosions, so that its complete restoration after 
the involution of the chancre generally takes place. 

Prognosis of the Chancre. — It has been maintained by some 
writers that the future course of syphilis depends to some extent on the 
size or number of the initial lesions, and that an extragenital location of 
the chancre is apt to be followed by a severer type of the disease. The 
character of the tissues on which the virus is implanted has more to do 
with, the future evolution of the constitutional disease than the size, number, 
or location of the primary sores. The most insignificant chancre may 
be followed by a malignant form of syphilis, while large and multiple 
initial sores may cause only a slight constitutional reaction. 

The chancre in patients with nephritis, diabetes, tuberculosis, or other severe 
systemic diseases may become gangrenous and produce extensive local destructio7i 
of the parts. Constitutional syphilis is also apt to be a more serious disease in such 
patients. 

Treatment of the Chancre. — In the opinion of the great majority 
of syphilographers at the present time it is not possible to abort syphilis 
by chemical agents or the actual cautery, nor by excision of the initial lesion, 
even in conjunction with removal of the inguinal ganglia. 

When a chancre is situated at the preputial margin in a patient with phimosis, 
it may be removed by a circumcision. No hope should be entertained, however, 
of preventing or modifying the future course of the disease by such procedure. 
It is only mentioned as a hygienic measure which may, under certain circum- 
stances, be indicated. The fact that immunity to further infection is present 
during the first period of incubation, before the characteristic sore has appeared, 
shows that some infectious matter has entered the general circulation, and that 
syphilis, before and at the time the chancre appears, is something more than a 
local disease. 

Local Treatment. — The sore should be kept clean by the free use of 
soap and water. Where an erosion or superficial ulcer is present, calo- 
mel is perhaps the best application to use until the raw surface has 
healed. The ordinary black wash, a solution of bichloride of mercury 
(1 : 2000 or 1 : 3000), or a solution of permanganate of potassium 
(1 : 3000) may also be employed several times a day as local antiseptic 
agents. 

When gangrene or phagedenic ulceration occurs as a complication, 
more active local medication is indicated. Compresses wet in a weak 



154 SURGICAL DISEASES. 

solution of chlorinated soda and kept constantly applied are an effica- 
cious method of limiting the spread of gangrene or phagedena. The 
free use of iodoform is also valuable in stimulating healthy granulations 
after the separation of the gangrenous mass or limiting a spreading ulcer- 
ation. After ulceration has healed the application of equal parts of mer- 
curial ointment and vaseline, mercurial plaster, or ointments containing 
other mercurials, hastens the absorption of the induration. Its absorp- 
tion is also more rapidly carried on during the internal use of mercury. 
Chancres on the female genitals should be treated in the same way, more 
care being here required, however, to preserve cleanliness. Chancres of 
the vulva should be freely covered with calomel and the parts kept sepa- 
rated by pledgets of absorbent cotton. An initial sore at the meatus or 
within the urethra is difficult to treat satisfactorily. When at the meatus 
it may lead to stenosis of this orifice if the canal is not kept open by 
means of a small roll of lint saturated with a dilute mercurial ointment 
or a tampon of iodoform gauze. Deeper-seated chancres may be treated 
by astringent injections, combined with the liberal use of mercurial oint- 
ment externally. 

If the initial lesion be in every way typical and the inguinal or other 
nodes present the characteristic enlargement, the internal use of mercury 
is indicated even before the eruption appears on the skin. 

Chancres always gives rise to much mental distress, and when on extragenital 
parts, as the face, are disfiguring. They may be painful when located on the 
glans or prepuce in patients with phimosis. In such cases, when the diagnosis is 
clear, one should not hesitate to resort to mercurials internally, as the involution 
of the sore is thereby hastened. When, however, the character of the sore is at 
all doubtful, one should await the appearance of the secondary eruption before 
beginning the general treatment. 

Constitutional Syphilis. 

The time between the appearance of the chancre and the outbreak 
of an eruption on the skin and mucous membranes is called the 
second incubation-period. Its average duration is forty-jive days: 
the shortest time reported is twelve days, the longest two hundred 
days. After experimental inoculation the shortest duration was eight 
to fourteen days ; the longest, one hundred and fifty-nine days. 
During and before this time a sloiv infection of the entire economy is 
taking place, which may produce a serious disturbance of the general 
health or be of such slight intensity that the patient is unaware of 
any change in his condition. A generalized hypertrophy of the lym- 
phatic nodes, in addition to those in direct communication with the pri- 
mary sore, can be made out by the end of this second incubation-period.' 
In some cases enlarged nodes can be detected two or three weeks before 
the skin-eruption appears ; again, not until or after the cutaneous out- 
break. The nodes along the posterior border of the sterno-eleido-mastoid 
muscle, other nodes about the neck, the supraclavicular, the axillary 
nodes, and the epitrochlear, are the ones which can usually be felt. In 
addition to those mentioned, any of the superficially located nodes may 
undergo hypertrophy, and the visceral nodes have been found enlarged 
in certain cases where autopsies have been made. The enlarged nodes 
vary in size from that of a bean to a pigeon's egg : they are rounded or 
oval in outline, painless, somewhat hard, and never suppurate unless 



SYPHILIS. 155 

some local condition produces a secondary infection. In tuberculous 
subjects previously enlarged nodes may become inflamed and even sup- 
purate, the syphilitic virus seeming to render active the bacillus of tuber- 
culosis, which is probably present at the same time. The duration of the 
enlargement is indefinite. It may pass away in a few months, a year, 
or some evidence of its presence may be detected after two or three 
years. When other causes are excluded the presence of a generalized 
lymphatic involvement may be of service in diagnosticating a past syphilitic 
infection after the cutaneous manifestations have disappeared. In late 
syphilis a gummatous or interstitial change, involving one or more nodes, 
has been occasionally observed. 

Among the evidences of a progressive intoxication of the system dur- 
ing this period, anaemia is frequently met with in a greater or less degree. 
Stoukovenkofif 's ' investigations showed that the first blood-change con- 
sisted in a rapid increase of the number of white blood-corpuscles, a 
diminution in the amount of oxyhsemoglobin and in the number of red 
blood-corpuscles. These blood-changes were found to be more pro- 
nounced in cases where fever was present. Bieginsky 2 has, in the 
main, confirmed these observations. 

The blood-changes are more pronounced in women than in men, 
sometimes producing a feeble action of the heart, extreme prostration, 
and other accompaniments of the anaemic state. The pathological state 
of the blood continues in a more or less marked degree during the erup- 
tive stage. 

Fever is present in a certain percentage of cases shortly before and 
during the early eruptive period. The majority of patients are affected, 
according to the observations of some writers, while less than half show 
febrile reaction, according to others. As a rule, the rise of temperature 
occurs only in the evening, and seldom exceeds 100° or 102° F. In 
exceptional cases it has reached 105° F. A form of intermittent fever 
has been observed during the existence of late visceral or nervous 
syphilis. 

Early syphilitic fever is a transitory manifestation, lasting, as a rule, 
but three or four days. It not infrequently precedes the outbreak of a 
pustular syphilitic eruption, and when accompanied by severe pain in 
the head and back the condition may closely simulate a variola. 

Pains of a neuralgic or rheumatoid character are often experienced in 
the joints, bones, and muscles. Sometimes an effusion into one or more 
joints can be made out, and not infrequently a painful thickening of the 
periosteum, especially over the long bones or cranium, is distinctly evi- 
dent. Localized or diffuse headaches of a severe character, with inability 
to sleep, or dull, ill-defined pains in the head, are often exceedingly 
troublesome. Ail the pains mentioned are intensified at night. 

Vertigo, epileptiform attacks, hysteria, temporary paralysis of certain muscles, 
analgesia of the extremities, increased tendon and skin reflexes are among the rarer 
manifestations of this period. Attacks of subacute pleurisy, enlargement of the spleen, 
and jaundice have been noted during the secondary stage of syphilis. 

The relationship of syphilis to other diseases, and the influence which 
it exerts on the healing of wounds, are interesting questions to consider. 

1 Ann. de Dermat. et Syphil., 1892, p. 928. 

2 Arch./. Dermat. u. Sypk, 1892, p. 43. 



156 SURGICAL DISEASES. 

Reference has been made to the increased gravity of the disease in 
tuberculous and alcoholic subjects. Bright's disease and rheumatism 
are aggravated when an added specific infection is present. A latent 
syphilis sometimes becomes active after 1 an attack of malaria. Some 
observations seem to show that fractures occur more readily in syphilitic 
subjects, probably as the result of local bone disease, and that their 
union is at times delayed. Cooper relates a case where the callus which 
formed around a fracture of the arm was rapidly dissolved by the admin- 
istration of iodide of potassium for a rupial eruption. 

A specific lesion of the skin, of subcutaneous tissues, or of bone may be local- 
ized by an injury or chronic irritation of the parts, but wounds or surgical opera- 
tions which are made during the active stage of syphilis heal as readily as on a 
non-syphilitic individual. A specific eruption, gumma, exostosis, or ulceration 
may rapidly disappear after an attack of erysipelas at the site of the lesions. A 
recurrence is apt to follow the disappearance of the erysipelas. 

Epithelioma may occur at the site of an ulcerating gumma of the 
skin or mucous membrane. An intimate relationship exists between the 
development of cancer of the tongue and the peculiar change in the 
epithelium known as leukoplakia, which sometimes follows specific 
lesions subjected to chronic irritation. 

Syphilis op the Skin; the Syphilides; Syphiloma. 

The administration of mercury during the second incubation-period, 
a greater resisting power on the part of the tissues, or other causes may 
retard the appearance of the specific eruption on the skin or mucous 
membranes. It must be borne in mind, however, that the disease is a 
constitutional one, with or before the appearance of the chancre, although 
at times slight evidence of its presence can be detected. In some 
instances the primary sore is of so doubtful a character that a diagnosis 
cannot with certainty be made before the appearance on the skin of the 
characteristic rash. As well-marked indurated chancres with inguinal 
lymphatic involvement have been observed that were not followed by 
any secondary eruptions, it is possible for syphilis to end its existence 
during the primary stage. 

In malignant, precocious, or galloping syphilis destructive lesions 
occur early in the course of the disease, anticipating by months or years 
their usual date of evolution. Gummata appear on the skin, mucous 
membranes, or in the viscera, producing deformity or the permanent 
impairment of the functions of important organs. A profound cachexia 
results from the intensity of the infection and the accompanying lesions. 
The historical account of the European epidemic of syphilis in the fif- 
teenth century shows that such forms were not so infrequent as they 
now are. 

The cutaneous eruptions of syphilis are the most constant and cha- 
racteristic manifestations of the disease : they are known as syphiloder- 
mata or syphilides, a qualifying adjective being employed to designate 
a special form of primary lesion or combination of lesions which is 
present. Syphiloma is a term which is sometimes used to include the 
late nodular or gummatous formations in the skin, mucous membranes 
and viscera. ' 



SYPHrLIS. 157 

All the primary and secondary lesions which are met with in non- 
specific dermatoses are also found in syphilitic ones. The latter can 
readily be recognized in the majority of cases by certain peculiarities of 
development, distribution, involution, color, grouping, polymorphous cha- 
racter, absence of itching, etc. Syphilis may imitate a psoriasis or lupus 
in its cutaneous expression, so that it is difficult to determine which affec- 
tion is present. It is incorrect, however, to refer to such an eruption as 
a syphilitic psoriasis or syphilitic lupus, as these terms would imply a 
combination of the two diseases ; which does not occur. 

The early syphilides occur in a symmetrical manner, have a general 
distribution, are superficially seated, disappear spontaneously, and pursue 
a more rapid course than the later ones. They show a tendency to lose 
their symmetrical distribution after a number of months have elapsed 
from the time of infection. The individual lesions composing the erup- 
tion now group themselves or assume circular or gyrate outlines, indi- 
cating to the trained observer a relapsing syphilide and also the proba- 
ble duration of the disease. 

The first eruption, which usually appears in the form of macules, is 
often followed, before its complete involution, by a papular, and this by 
a pustular or ulcerative, syphilide, so that a mixed or polymorphous erup- 
tion is present. 

The color of syphilitic lesions is due in great measure to the marked implica- 
tion of the blood-vessels in the pathological process, which favors blood-stasis and 
exudation of the red blood-corpuscles into the tissues. The pigment which results 
from their disintegration in greater or less amount gives to the lesion a lighter or 
darker shade. At first the lesions may have a pinkish-red color which soon 
assumes a brownish or yellowish-red tint that has been compared to the color of 
raw ham or copper. A yellowish or brownish-black pigmentation may remain 
at the site of the lesions after their disappearance. Exceptionally, the absence of 
the normal skin-pigment, leukoderma, may mark the location of the lesions. It 
should be remembered that other skin affections may present equally marked pig- 
mentary changes, and that the color of the eruption is only of diagnostic value 
when taken in conjunction with other features. The absence of itching, burning, 
or other subjective sensations in connection with the eruption is of diagnostic 
importance. 

The later or tertiary cutaneous manifestations of syphilis differ from 
the earlier ones in their irregular and exceptional occurrence, their local- 
ized distribution, deeper seat in the tissues, slower course, and in their 
tendency to cause loss of tissue and leave permanent cicatrices. The cen- 
tral involution and peripheral extension of the infiltration is also more 
marked in the late syphilides 1 . The secondary lesions contain the virus of 
syphilis in an active state, while the tertiary lesions are slightly if at all 
virulent. Experimental inoculation of the secretions of late syphilides 
has invariably given negative results. 

The specific influence of mercury on the early eruptions, and of the 
iodides in causing the disappearance of the later ones is a remarkable 
instance of the selective action of drugs in different stages of the same 
affection. In many cases the two stages are not separated by well- 
defined limits, but are united by intermediate eruptions which present 
many of the characteristic features of both. 

Roseola syphilitica, the macular or erythematous syphilide, is usu- 
ally the first cutaneous manifestation of syphilis. It appears at the end 
of the second incubation-period as a generalized eruption of circum- 



158 



SURGICAL DISEASES. 



scribed spots of hyperemia from the size of a split pea to that of the 
finger-nail. The spots are bright-red or bluish-red in color, and are not 
elevated above the skin-level. The eruption begins, as a rule, on the 
abdomen, then on the chest, and finally on the extremities. The face is 
exceptionally attacked. A week or two elapses before the eruption 
appears on the extremities. It may last for several days or several 
weeks, and usually disappears without desquamation, leaving at times 
light-brown pigment-spots to mark its former situation. 

The papular syphilide may be the first eruption or follow the 
macular syphilide. It occurs in the form of large or small papules, 
constituting the lenticulo-papidar and the miliary-papular eruptions. 
The papular eruptions are generalized in the early months of the dis- 
ease (Plate VI.) ; later, their distribution is circumscribed, and finally 
they may form transition types from the early to the later tubercular or 
gummatous new formations. The papule is the initial form of all the 
subsequent secondary lesions. It varies in size from a pin's head (the 
miliary papule) to that of a split pea and larger (the lenticular papule). 
It consists of a sharply circumscribed, solid infiltration in the derma, of 
a light-red or brownish-red color, projecting above the level of the skin. 
When not the seat of secondary changes, as suppuration, it heals with- 
out scarring. In its declining stage it frequently scales, forming the 
papulosquamous syphilide, a common form and one often mistaken for 
psoriasis. 

On the palms and soles a number of scaling lesions may coalesce, giving rise to 
the eruption which has been erroneously called syphilitic palmar and plantar psoriasis. 
Annular and gyrate forms result from the central involution and peripheral exten- 
sion of the lesions. The papule maybe surmounted by a vesicle, bulla, or pustule, 
giving rise to a great variety of lesions to which distinct terms have been applied, 
as the varicella-form, the variola-form, the impetigo-form, the eothyma-form, and the 
acne-form of the syphilides. It should be remembered that all these forms of 
eruption represent changes which take place in the papule and follow its localiza- 




Grouped papulo-pustular syphilide and numerous pigmented spots from former lesions. 



tion, size, and outlines, papular, pustular, and transition forms of eruption being 
frequently seen on the same patient (Plate VII. and Fig. 34). They do not repre- 
sent essentially different lesions, but occur, as a rule, after the papule is developed 
from some condition of the patient or an increased virulency of the syphilitic 
poison. 

The ecthyma-form syphilide, or the large pustular variety, occurs 



PLATE VI. 









Grouped Miliary Papular Syphili 



de. 



PLATE VII. 





Mixed Papular and Papulo-Pustular Sypbilide. 



SYPHILIS. 



159 



by preference on the lower extremities or scalp as a superficial or deep 
affection, giving rise to large, irregularly-shaped ulcers, having a livid, 
grayish, or gangrenous floor which secretes a bloody pus that dries in 
the form of dark-brown or black crusts. Ulceration extends beneath 
the crusts. This type of eruption is rarely seen during the first six 



Fig. 35. 




Ulcers resulting from the deep ecthyraatous syphilide. 

months. It is more usual as a late secondary or intermediate eruption. 
In Fig. 35 two symmetrically situated ulcers on the legs are shown 
which are the result of this form of the syphilide. 

Rupia, or the rupial syphilide, is a form of the large pustular erup- 
tion resulting in ulcers which are covered by concentric layers of crusts. 
It may occur within the first six months as a precocious eruption, as a 
late secondary, or as a tertiary outbreak. The papule, if it exist at all, 
has a very transient duration, the first lesion being a bulla or pustule. 
The secretion is abundant, thick, and dries rapidly in superimposed 
layers of greenish-brown or blackish-brown crusts, beneath which the 



160 SURGICAL DISEASES. 

ulceration extends on all sides : as a consequence, each newly-formed 
layer is larger than the one which precedes it, which gives to the lami- 
nated layers a conical shape (Plate VIII.). If the crusts are removed, 
an indolent ulcer with an irregular base and undermined edges is revealed, 
which is frequently slow in healing. Irregularly rounded, depressed 
white scars, surrounded by a pigmented areola, are left after the ulcer 
heals, and are quite characteristic of a past syphilis. A rupia is pathog- 
nomonic of syphilis, as no other dermatosis assumes such a form. 

The prognosis of this eruption is not favorable in its severe and 
generalized forms. It is slow in healing, and death has resulted from 
sepsis due to absorption of purulent matter beneath the crusts. By 
careful local and general treatment the majority of cases terminate in 
recovery. 

Ulceration ivith permanent scar-formation may result from any of the pustular 
eruptions during the secondary stage. The existence of ulcers in syphilis does not 
imply, therefore, that the disease has reached the so-called tertiary stage. A pap- 
ular eruption on the trunk is apt to be accompanied by pustules on the scalp and 
hairy portions of the leg, as if the papules in these localities had been infected by 
pus-organisms. 

Tertiary Syphilis. 

The statistics of Haslund l show that tertiary syphilis in general 
occurs in about 12 per cent, of all cases infected. The skin is involved 
more frequently than any other tissue or organ, and nearly as often 
as all the other organs combined. If we assume that tertiary lesions 
develop at the site of the earlier ones from latent virus that is rendered 
active by irritation or other causes, the increased frequency of skin 
lesions in late syphilis can be explained by the more frequent implica- 
tion of the skin during the secondary stage, and its greater liability to 
traumatisms and irritation. 

The syphilides of the late period of the disease are the tubercular 
or nodular and the gummatous. The former are found in the superficial 
or deeper layers of the skin as grouped or discrete, circumscribed, brown- 
red nodules, from the size of a pea and larger, which may coalesce into 
large, flat areas of infiltration. The nodule or tubercle resembles the 
early papule in its histological structure, and is considered by some 
writers to be a more highly developed form of this lesion. In its early 
tendency to degeneration and ulceration, producing atrophy and scarring 
of the skin, it is closely related to the gumma. Both the nodule and 
the gumma are considered by many syphilographers as varieties of the 
same lesion. The tubercular syphilide can exceptionally undergo absorp- 
tion without leaving a scar. As a rule, it spreads in a serpiginous man- 
ner, healing with loss of tissue, and advancing by a broken, elevated 
margin which represents the most recent deposit. In this way it pro- 
duces lesions with the outlines of circles, segments of circles, and horse- 
shoe- and kidney-shaped infiltrations. When absorption takes place with- 
out ulceration, a clinical picture is formed sometimes closely resembling 
lupus vulgaris (Fig. 36). 

The serpiginous infiltration, instead of undergoing interstitial absorption, as in 
the last form, may ulcerate, become infected, and secrete pus or pus mixed with 

1 "On the Causation of Tertiary Syphilis," Brit. Journ. of Dermal., 1892, p. 210. 



PLATE VIII. 






• 



% 



Early Rupial Syphilide. 



PLATE IX. 





Tubercular Ulcerating Syphilide, showing lesions 
in different stages. 



SYPHILIS. 



161 



blood, which dries in the form of yellowish-gray or greenish-black crusts, giving 
rise to the tubercular ulcerating or the pustulo-ulcerating syphilide. A part or the 
whole of the marginal infiltration may break down, and numerous foci are some- 
times met with in various stages of development (Plate IX.). 

The entire duration of the tubercular syphilide may, in severe cases, be fifteen 
to twenty yean. The ulcerating serpiginous syphilide develops at times from the 
papulo-pustules of the late secondary or intermediate period of syphilis. The 
cicatrices resulting from these forms of syphilide are generally white, superficial, 
smooth, with scalloped or irregularly outlined borders, surrounded by a pigmented 
zone, and are quite suggestive of the condition which preceded them. The scar- 
tissue is less than would be anticipated from the appearance of the active stage of 
the disease. 

The Gummatous Syphilide. — The true tjiuniiia begin*, as a rule, in 
the subcutaneous tissue, affecting the skin secondarily. It is observed as 
a round or oval tumor, from the size of a cherry or smaller to one as 
large as the fist. The gummy tumors in the beginning are hard, elastic, 

Fig. 36. 




Tubercular serpiginous syphilide resembling lupus vulgaris. 



sharply circumscribed, and freely movable beneath the skin, which may 
not be elevated. This may be painful or only slightly sensitive to 
pressure. In their development they may become attached to the tis- 
11 



162 



SURGICAL DISEASES. 



sues beneath, as well as to the overlying skin, forming projecting tumors 
which closely resemble other non-specific growths. The skin covering a 
gumma which has undergone central softening becomes somewhat red- 
dened and swollen, or it may be the seat of a nodular infiltration. An 
examination at this stage reveals distinct fluctuation : an incision made 
into the growth gives exit to a thick, viscid, mucilaginous-looking fluid 
of a yellowish-gray color containing few pus-corpuscles. The appear- 
ance of the contents of the broken-down gumma has given the growth 
its name. The tumor may be absorbed during the stage of fluctuation, 
leaving the skin covering its former seat thin, depressed, and somewhat 
pigmented. The subcutaneous and cutaneous tissues have been in part 
destroyed by the new growth, so that a permanent atrophy of the 

affected area remains. The 



detritus of the gummy tumor 
at times undergoes a cheesy 
or calcareous degeneration 
which becomes encapsulated 
or is eliminated by ulceration. 
One or several openings form 
over a softened gumma, giv- 
ing exit to disintegrated and 
sloughing tissue : these open- 
ings may unite, forming a 
single gummatous ulcer, or 
remain distinct (Fig. 37). 
The ulcer is at first smaller 
than the cavity and surround- 
ing infiltration : its edges are 
thickened, bluish-red, and 
undermined, its base being 
made up of the degenerated 
tissue of the gumma. The 
ulcer remains open until all 
the affected tissue has been 
softened and expelled. The 
reparative process is slow, 
and may be complicated and 
delayed by infection of the surrounding skin, gangrene, phagedena, etc. 
The ulceration may furthermore extend deeply, involving the underlying 
muscles and bones. Necrosis of the tibia, skull, and other bones follows 
at times a chronic gummatous ulceration. Deformity and contraction 
may result from deep destruction of tissue about the joints, the lip, or 
the eyelids. A thickening of the lower extremities, face, and elsewhere, 
allied to elephantiasis, has followed the destructive process. 

The subcutaneous gumma is generally a single growth : a group of 
half a dozen or more may be seen, however, which forms a characteristic 
picture when the stage of ulceration begins. The cicatrices are depressed, 
circular, white, with a pigmented margin, and may be adherent to "the 
bone or subcutaneous tissue. A group of such scars would suggest the 
nature of the affection which produced them, while a single cicatrix 
might not be at all characteristic. 




An ulcerating gumma of the leg. 



SYPHILIS. 163 

G-ummata are the most important syphilitic neoplasms from a surgical 
standpoint, as they frequently occur without other symptoms of syphilis 
and closely simulate other conditions. They have been mistaken for 
abscesses, sarcomata, lipomata of the subcutaneous tissue, for malignant 
disease of the tongue, the muscles, the breast, etc., and for tuberculosis 
of the bones, testicle, and other organs. Deep-seated nodules of the 
subcutaneous tissue are sometimes seen in scrofulous subjects, which 
adhere to the skin, ulcerate, and present almost identical features with 
the syphilitic affection. They are usually symmetrical and heal with 
scarring, or, if atrophy takes place without ulceration, the loss of tissue 
may not be pronounced. 

The chronic ulcer of the leg in subjects with varicose veins differs 
from the gummatous ulcer in its more frequent localization on the lower 
part of the leg, its chronic course, and in the absence of any feature 
suggesting syphilis. Syphilitic ulcers occurring in such patients at times 
lose all their surrounding infiltration and are converted into simple 
ulcers. 

Ulcers following localized gangrene due to obliterative endarteritis, 
gangrene of the extremities necessitating amputation, and the symmet- 
rical form of gangrene of the extremities — Raynaud's disease — have 
been observed to develop during the course of syphilis. 

Pathological Anatomy of the Syphilitic Inflammation. — 
An implication of the blood-vessels is met with in all stages of the 
disease. The connective-tissue elements of the vessel, as well as the 
intima, are the seat of a proliferative inflammation which often leads to 
its occlusion. 

A section from a secondary papule properly prepared shows a fibrosis and leu- 
cocytic infiltration of the vessel's coats. The inflammatory cells, which are at first 
confined to the immediate vicinity of the blood-vessel, soon become generalized. 
These cells usually undergo necrosis and are absorbed. The degeneration begins 
in the oldest part or centre of the lesion, while an active cell-growth takes place 
at the periphery. This method of involution and evolution of the infiltration 
explains the ringed and serpiginous outlines which many eruptions assume. 

The necrosis of the cells is more pronounced in certain types of eruption than 
in others. In the pustular lesions it takes place so rapidly that frequently a typical 
papule does not form. In both the initial lesion and in the non-suppurative syph- 
ilide the cell-degeneration can be distinctly seen in the microscopic sections. In 
these lesions, as well as in syphilis in general, there is little tendency on the part 
of the newly-formed cells to organize into permanent connective tissue. 

An exception to this rule is found in certain visceral affections due to syphilis 
where connective-tissue growth occurs, either as a result of the vascular changes 
in the parts or directly from the action on the cells of the specific virus. 

It follows, too, on gummatous deposits in the liver, the lungs, the testicle (Fig. 
70), and other organs, causing pressure on and destruction of the implicated tissue. 
The fibrous tissue which surrounds gummata of the skin and subcutaneous tissue 
does not show the same tendency to spread as a similar condition in the viscera or 
nervous system. 

In congenital syphilis both the liver and spleen are very often enlarged from an 
infiltrating growth of connective tissue. The first changes consist of a small-celled 
■deposit about the branches of the hepatic artery or portal canals, which becomes 
later more generalized and organizes into connective tissue or degenerates into 
miliary gummata. As the greater part of the arterial blood in the foetal circula- 
tion passes directly through the liver, it can be easily understood that when this 
blood is charged with the toxines or bacteria of syphilis the first and most pro- 
nounced effect may be manifested on this organ. 

Histology of the Gumma. — These neoplasms begin as small 



164 SURGICAL DISEASES. 

round-celled infiltrations in the connective tissue with a tendency to 
peripheral extension. Giant cells may be found in the advancing mar- 
gin. The centre of the gumma undergoes a necrosis which involves 
not only the recent infiltration, but the connective tissue of the part as 
well, leading to a permanent destruction of the implicated tissue. 

The blood-vessels of the gumma are not so numerous, nor do they 
play so important a role, as in the early processes. The characteristic 
pathological feature of the gumma consists in a degeneration of the con- 
nective tissue, of a hyaline and fatty character, which may be expelled 
or dry into a cheesy mass. 

In the viscera the contraction of a cavity resulting from a disinte- 
grated gumma results in considerable deformity of the implicated organ ; 
and in the central nervous system, where loss of tissue is of vastly more 
importance than in the skin, it may produce consequences which are 
irreparable. 

Syphilis of the Mucous Membranes — Most of the eruptions 
which are seen on the skin may be found on the mucous surfaces, their 
appearances being altered by the local heat, moisture, and irritation to 
which they are subjected. A sharply-defined erythema of the fauces 
and soft palate usually accompanies the macidar eruption. A syphilitic 
vaginitis and urethritis have been noted. It is quite probable that 
other mucous membranes, which cannot be inspected, are also the seat 
of similar catarrhal inflammations. 

Mucous patches or plaques, which represent the cutaneous papule, 
frequently occur on the genitals of women before the outbreak of the 
eruption on the skin, their development being favored by local heat and 
moisture. In this locality and where similar conditions are present, as 
about the anus, beneath the breast, at the angle of the mouth, etc., the 
papule becomes abraded, hypertrophied, or is covered by a grayish- 
white membrane, and at times ulcerates. These vegetating hypertrophic 
and other abraded papules in such places are called condylomata lata, to 
distinguish them from the pointed warts, or condylomata acuminata, 
which are not syphilitic. They secrete a thin, watery fluid and are a 
potent source of contagion. At the angle of the mouth they may be 
fissured and painful from the movement of the parts. 

Mucous plaques in the mouth arise from the modified papule, and 
exist in the papulo-erosive, the papulo-hypertrophic, and the papulo- 
ulcerative forms. The epithelial covering of the lesions is macerated 
and assumes a grayish-white or opaline appearance. The patches may 
vary in size, from a line or two to half an inch or more in diameter, and 
are slightly elevated above the surface. The edge of the tongue and 
inner side of the lip are favorite sites for them. They show a marked 
tendency to recur after healing, especially in smokers, and are often 
seen after other evidences of the disease have passed away. 

These late and recurring lesions lose their moist character, become 
quite smooth, shiny, of a bluish-white color, and may mark the begin- 
ning of the condition known as leukokeratosis. This affection of the 
mucous membrane of the tongue and buccal cavity not infrequently 
follows local syphilitic lesions which have been subjected to chronic 
irritation. It also occurs in individuals who have never had syphilis 
and are not smokers. It is not influenced by anti syphilitic remedies, 



SYPHILIS. ] 65 

and must be regarded as the result of the disease rather than as syphil- 
itic per se. 

Leucokeratosis appears as circumscribed or diffuse smooth patches 
of a bluish-gray color over the tongue and on the mucous membrane of 
the cheek, extending backward in radiating lines or bands from the angle 
of the mouth. The epithelium covering the patches becomes thickened, 
fissured, and may be the seat of an epithelioma. Its surgical interest 
depends on the frequency with which it is followed by this malignant 
growth. 

Ulcerative lesions of the tongue or any part of the buccal cavity 
may follow disintegration of the papule, the nodular, or gummatous 
deposits. Such ulcerations sometimes spread at their margins, and may 
assume the outlines of the corresponding cutaneous eruptions. 

Gummata of the tongue begin as single or multiple, deep-seated, 
pea-sized, or larger tumors, over which the mucous membrane may be 
quite normal. These gummata develop slowly, without pain, and may 
reach the size of a pigeon's egg before undergoing resolution or break- 
ing down. When they ulcerate a small opening appears over their 
central portion, which rapidly enlarges to an abscess-cavity. 

The differential diagnosis between epithelioma and ulcerating gumma 
is not always easy. In general terms, it may be stated that cancer is 
usually single, while the syphilitic neoplasm is often multiple. The 
ulceration in cancer is superficial, painful, bleeds easily, discharges 
freely, and is often the seat of papillary outgrowths ; its edges are more 
elevated and the induration about the ulcer more pronounced. 

The communicating lymph-nodes are soon implicated in the cancer- 
ous disease, while they are absent after the late specific neoplasm. An 
epithelioma may develop on a gummatous ulceration. In such a case a 
differential diagnosis is at times only possible after a microscopic exam- 
ination. 

Interstitial Glossitis. — In late syphilis, as a result of an interstitial 
sclerosis involving the muscular structure, a part or the whole of the 
tongue becomes greatly hypertrophied. Later, from contraction of the 
fibrous tissue, the tongue grows smaller, its mucous membrane becomes 
smooth, deep furrows form over the tongue which cannot be effaced by 
stretching, and the organ is harder and less movable than normal. A 
permanent deformity of the tongue results which is little influenced by 
treatment. 

Hereditary Syphilis. 

Syphilis may be transmitted by the mother through the infected ovum ; 
by the father, through the infected spermatozoon ; or bj/ both parents. A 
mother who acquires syphilis after impregnation has taken place may 
transmit the disease to the foetus through the utero-pl a cental circulation. 
The later such infection takes place after conception the less probability 
is there that the child will be affected. When transmission takes place 
under the last condition — utero-placental infection — the placenta is found 
to be diseased, and no longer acts as a filter to retain the hypothetical 
microbe. A child born from a mother who is infected with syphilis in 
the late months of her pregnancy may be healthy, but is immune to sub- 
sequent infection, as are other healthy children of syphilitic parents 



166 SURGICAL DISEASES. 

(Profeta's law). Such a child may be delicate, ansemic, and have little 
resisting power to other infectious diseases, or may develop a late hered- 
itary syphilis. A healthy mother who gives birth to a syphilitic child 
from the father may be infected with the disease through the utero-pla- 
cental circulation : she may acquire a modified form of the disease, which 
manifests itself in cachexia, impairment of the general health, or by late 
syphilitic lesions ; she may remain healthy with an acquired immunity 
to subsequent infection (Colles-Baumes' law). When pregnancy occurs 
with recent syphilis in one or both parents, it results in the death and pre- 
mature delivery of the foetus ; the birth at term of a dead child ; a living 
child with the disease in an active stage ; or of one in which the disease 
does not manifest itself for several weeks to two or three months after 
birth. Either parent may, in exceptional instances, transmit the disease 
after healthy children have been born. The longer the time between 
infection and impregnation, however, the less chance there is of transmit- 
ting the disease by inheritance, and the milder the disease when so con- 
veyed. The infectiousness of the virus is generally weakened by treat- 
ment and time, but no one can say when it ceases. 

The prognosis in congenital syphilis is much more grave than in 
acquired. The greater number of children born with the active disease 
die soon after birth. When its symptoms are delayed until the first or 
second month, if the nutrition is not bad, recovery generally takes place 
under proper treatment. From one-third to one-half of all cases die 
before reaching adult life. 

Symptoms. — The early symptoms of congenital syphilis appear in 
the majority of cases within the first three months, never later than the 
fifth month. Nearly half the cases present some sign of the disease 
within the first month. If no evidence of the disease is present during 
the first six months, the child, as a rule, remains well, or at most develops 
a form of late hereditary syphilis. 

Syphilitic children are poorly nourished, and remain deficient in both 
their physical and mental development. They have little resisting power 
to other disease, and not infrequently acquire tuberculosis, rachitis, or 
other disorders of nutrition. 

Nasal catarrh — snuffles — from a specific affection of the mucous membrane of the 
nose, is one of the most common of the first symptoms of the disease : this is fol- 
lowed or accompanied by a modified erythematous rash, of a patchy character, 
over the abdomen, about the anus or thighs —by mucous patches and fissures at the 
angles of the mouth or about other apertures. A generalized erythematous, pap- 
ular, or a mixed eruption is at times present. On the palmar and plantar surfaces, 
occasionally on other parts of the integument, the eruption assumes a bullous or 
pustular character. This so-called pemphigus syphiliticus develops because of the 
delicate character of the epidermis over the specific infiltration. The papules 
about the anus and mouth readily break down and form superficial ulcers. 

Papulosquamous eruptions may be found localized on the face, the extremities, 
the trunk, or generalized. Later in life the nodular or gummatous syphilide may 
be met with, which presents the same appearance as in the acquired disease. 

A frequent and characteristic affection of the long bones, known as 
osteochondritis syphilitica, in some cases closely resembling rachitis, occurs 
early in hereditary syphilis. A swelling takes place at the junction of 
the epiphysis and diaphysis which may resolve under treatment, or in 
severe cases ulcerate with extrusion of the diseased epiphysis. Bony 



SYPHILIS. 167 

union may take place between the epiphysis and diaphysis, or abnormal 
ossification follow, which can result in shortening or deformity. Par- 
rot's opinion that rickets was always due to hereditary syphilis is not 
now accepted. 

Circumscribed or diffuse thickenings of the bones of the skull, espe- 
cially the frontal and parietal bones, combined with atrophy of the bone- 
substance in places, is common in congenital syphilis. 

An osteitis and periostitis of the phalanges — dactylitis syphilitica — 
occurs in both hereditary and acquired syphilis. 

Hutchinson first called attention to a deformity of the upper central 
incisor teeth of the second set which he looked upon as diagnostic of hered- 
itary syphilis. When cut, these teeth are short, narrow, and thin. After 
a time a notch is formed by the breaking away of a crescentic portion 
from their edges, which is permanent for some years. The appearance 
described is often absent in syphilitic patients, or may result from other 
causes. 

Sudden deafness without pain or purulent discharge in a young per- 
son points to hereditary syphilis (Hutchinson). When deafness, inter- 
stitial keratitis, and the notched teeth are present in the same patient, the 
diagnosis of congenital syphilis is looked upon as positive. 

Treatment. — Syphilis in healthy individuals of early adult life is, 
in the majority of cases, a benign affection, often disappearing without 
treatment, and producing little if any impairment of the general health. 
Unfortunately, we have no certain means of determining when the dis- 
ease is cured, or of foretelling the cases that will prove mild and of 
short duration, and those that may involve important organs and 
endanger the future health, or even the life, of the patient. 

It is, therefore, of the greatest importance to explain to one suffering 
with the disease the necessity of systematic and prolonged treatment, 
not only during an active outbreak of symptoms, but during the latent 
periods as well. 

When any doubt exists regarding the character of the primary sore, 
treatment should not be begun until the appearance of the first cutaneous 
eruption. The future course of the affection is probably not at all 
influenced by such delay, and both the surgeon and patient are assured 
of the certain existence of syphilis, and both are more active in carry- 
ing out a prolonged treatment than if a doubt exists regarding the 
diagnosis. 

The presence of a sclerosis on extragenital parts or the early occur- 
rence of severe general symptoms during the second incubation-period 
may be indications for the use of mercury before the characteristic rash 
has developed. Many surgeons who have had a wide experience with 
the disease do not hesitate to begin the use of mercury when a character- 
istic chancre and its accompanying adenopathy are present. 

Before the use of mercury is begun the patient should consult a dentist and 
have the teeth put in good condition. If all cavities are filled and the tartar 
removed from the teeth, larger doses of mercury can he taken with less liability to 
salivation. 

Alcohol in all forms should be prohibited unless some special indica- 
tion may arise for its use. Smoking should not be allowed, as it is apt 



168 SURGICAL DISEASES. 

to irritate mucous patches in the mouth or throat and to determine suc- 
cessive outbreaks of such lesions. Syphilitic mucous patches irritated 
by tobacco-smoke terminate at times in leucokeratosis and epithelioma. 
Attention to the ordinary laws of hygiene should be insisted on, and 
every means employed to preserve the patient's health. Iron, tonics, 
cod-liver-oil, etc. may at times be indicated in conditions which arise 
from syphilis, as well as from other causes. They possess no specific 
action on the syphilitic virus, however, and are sometimes employed for 
an ansemia which mercury or the iodides can only control. 

The contagious character of the syphilitic secretions and discharges 
and the necessity of great care in the family and other intercourse 
should be explained in detail to the patient. 

If marriage takes place during the contagious stage of the affection, 
or if the disease develops after marriage, the patient must be informed 
of the danger to the wife and offspring which will follow the advent of 
pregnancy. 

The two specific remedies which we possess are mercury and iodine, 
the latter usually given as potassium iodide. Certain vegetable reme- 
dies, like sarsaparilla and guaiacum, are occasionally used as auxiliaries. 
Mercury exerts a pronounced specific influence over the local and consti- 
tutional manifestations of the primary and secondary stages, and it is 
not without curative effect in the later stages. 

The potassium iodide causes the rapid disappearance of local lesions 
and general symptoms in the tertiary stage. It is useful in combination 
with mercury when early pustular and ulcerative lesions occur, and in 
the late secondary and intermediate stages of the disease. 

Mercury alone is the remedy with which to begin the treatment of 
syphilis. It may be given by the stomach, by inunction, by hypodermic 
injection, or by fumigation. The most convenient and generally employed 
method is by the stomach, and in the majority of cases it is not neces- 
sary to resort to other means of introducing it into the system. It 
should be given in sufficient doses to exert a prompt effect on the dis- 
ease, and yet care must be observed to avoid salivation and diarrhoea. 

The condition of the mouth must be carefully watched, and as soon 
as the gums become tender and swollen or show a disposition to bleed 
the administration of mercury must be stopped for a few days, or, better, 
the number of doses or the quantity given reduced. 

A wash of alum and potassium chlorate, ad. $j, to a pint of water, should be 
frequently used to prevent and relieve this condition of the mouth. Saline laxa- 
tives, administered during the existence of a mercurial sore month, hasten its cure 
by eliminating the drug more rapidly through the bowels. 

In pronounced ptyalism, with swollen and spongy gums and superficial abra- 
sions of the mouth, mercury should be promptly discontinued. The flow of saliva 
in such cases is limited by atropine, in doses of ^ of a grain every four hours. 

The mercurial stomatitis may be quickly relieved by carefully painting the gums 
with a 2 to 5 per cent, watery solution of chromic acid once a'day, in addition to 
the other measures mentioned, care being taken that the mouth is thoroughly 
rinsed with water thereafter. 

The protoiodide of mercury, in pill or tablet form, given in doses of 
gr. | to gr. 1, t. i. d., has had a wide popularity and islargely used as a 
routine treatment of secondary syphilis. It is not as efficient as the 
other preparations mentioned, and is apt to give rise to gastro-intestinal 
irritation when used in larger doses. 



SYPHILIS. 169 

The tannate of mercury, in doses of from \ to 1 grain, t. i. d., is an 
active drug, and is said to produce less stomach and bowel disturbance 
than the protoiodide. 

For the relapsing eruptions of the late secondary stage it is some- 
times of advantage to give the biniodide of mercury in doses of •£% to -^ 
of a grain dissolved in an excess of iodide of potassium. 

When early pustular and ulcerative lesions are slow in healing the 
quantity of the iodide in the last prescription may be increased. 

During the first six months the use of one or another of the prepara- 
tions mentioned should be kept up pretty constantly. At the end of 
this time, if no symptoms of the disease are present, medication may be 
discontinued for a month or six weeks, and then resumed for three or 
four months. A longer period of rest may then be permitted, followed 
by a third course of mercury or mercury combined with the iodide. 

If the patient's health keep good and no indications arise against its 
use, a fourth or fifth mercurial course may be advised. 

Inunction Treatment, — This method has the great advantage of 
not so readily disturbing the digestion, and when, for any reason, the 
internal use of mercury is not well borne inunctions should be advised. 

It is the most efficient and rapid method in causing the symptoms to 
disappear. It is disagreeable, uncleanly, cannot readily be concealed, 
and requires considerable time to be properly carried out. 

At health-resorts, like Hot Springs in Arkansas or Aachen in -Ger- 
many, where experienced rubbers can be employed, it is the method 
which is almost exclusively used in early syphilis. 

The patient should be directed to rub one drachm of the unguentum 
hydrargyri each day, for a period of twenty to thirty minutes, over a 
limited portion of the integument until the body has been completely 
covered. The legs may be chosen for the first day, the thighs the second, 
the back the third, the arms the fourth, and the chest and abdomen for 
the fifth day. At the end of this time the same course should be 
repeated. From thirty to fifty inunctions may be given, followed by a 
period of rest for a month or six weeks. At the end of this time 
another inunction-treatment should be employed or mercury given by 
the stomach. 

In syphilis of the viscera or nervous system the inunctions can be 
advantageously combined with the administration of the iodides. 

Hypodermic Treatment. — Of the many soluble and unsoluble salts 
of mercury which have been advocated for hypodermic and intramus- 
cular injections, corrosive sublimate is probably the most efficient and 
least dangerous. The following formula and method are given by 
Cooper l for its employment : 

1^. Hydrarg. bichlor., gr. xxxij ; 

Ammonii chlor., gr. xvj ; 

Aqua? dest., §ij. — M. 

SiG. Ten minims to be used for one injection. 

The injection should be given through a platino-iridium needle pre- 
viously sterilized. The gluteal region is the most convenient site to be 
1 Syphilis, Alfred Cooper, 2d ed., 1895. 



170 SURGICAL DISEASES. 

chosen. The point of the needle is inserted into the gluteus maximus 
muscle and the solution slowly injected. One injection a week is given 
for six or seven weeks, and then at longer intervals. By means of these 
intramuscular injections a sure and rapid mercurialization of the patient 
is effected, and in certain emergencies they are to be recommended. As 
a routine method of treatment, however, they cannot be advised, and 
few patients will submit to them. 

Local treatment is often necessary for certain lesions of the secondary 
and tertiary stages. For the condylomata lata about the genitals, anus, 
and other regions the free use of calomel is the most efficient agent. 

Mucous patches on the lips and mouth should be cauterized with the 
nitrate-of-silver pencil or a chromic-acid solution (gr. xx— xxx to aq. 3j). 

Ulcerations in the throat may be sprayed with a solution of bichloride 
of mercury (gr. ss-j to aq. §j). 

Localized eruptions disappear more rapidly after the application of an ointment 
containing mercury. When on the face, a dilute ammoniated mercury or calomel 
ointment should be employed to avoid the stain left by the blue ointment. Specific 
infiltrations of the tertiary stage are favorably affected by the local use of mercu- 
rial ointments or plasters. Mercury is contraindicated in syphilis when tuberculosis 
exists, in nephritis not due to syphilis, and in pronounced ansemia from other 
causes. Pregnancy is an indication for its vigorous employment. 

Congenital syphilis should be treated by hydrarg. cum creta, gr. j, 
t. i. d., or, better, by the use of inunctions of blue ointment, gr. xx, 
once a day, thoroughly rubbed into the body. The ointment should be 
diluted with vaselin, to prevent its irritant effect on the delicate skin 
of the infant. 

Indications for the Use of the Iodides. — The iodides are frequently 
given between courses of mercury or after the completion of the mer- 
curial treatment, for the purpose of rendering soluble and eliminating 
the mercury which may remain in the tissues. Their most striking effects 
are produced in the late stages of the disease in causing the rapid disap- 
pearance of gummata, and other specific infiltrations, and in the healing 
of syphilitic ulceration of the skin and mucous membranes. No other 
therapeutic agent can produce so marked and rapid effects as the iodides 
in late syphilitic neoplasms. 

Certain persons are very sensitive to the iodides, small doses pro- 
ducing catarrhal symptoms in the nose, throat, and bronchial tubes. 
Tolerance, of the drug in such patients may generally be acquired by 
beginning with minute doses and slowly increasing the amount taken. 

Papular, pustulous, bulbous, erythematous, nodular, and purpuric erup- 
tions are at times produced by the ingestion of the iodides. Certain of 
these eruptions may be confounded with syphilitic lesions. 



CHAPTER XI. 

GONORRHOEA AND ITS SEQUELS. 

By W. T. Belfield, M. D. 



Etiology. — Gonorrhoea is an infection of human tissues by a specific 
bacterium, the micrococcus or gonococcus of Neisser, reinforced by one or 
more varieties of the common pus-bacteria ; practically, it is therefore a 
mixed infection. 

The gonococcus is not only an obligate parasite — never found except 
in animal tissues — but it is also a parasite of human tissues only, other 



far as known, being an 
is acquired only by con- 



unfavorable 



its growth. 




animals, so 
Hence it 

tact, direct or indirect, with a suf- 
ferer from the disease. The com- 
monest seat of the infection is the 
genito-urinary tract of male and fe- 
male, and it is hence usually trans- 
mitted by sexual contact. Yet cer- 
tain other mucous membranes are 
susceptible to the infection, and it is 
occasionally carried indirectly — by 
soiled fingers, towels, and syringes, 
or by unnatural intercourse — to the 
mucous membrane of the eye and 
rectum, even of the mouth and nose. 

While all accessible mucous mem- 
branes may be infested by tbe gonococ- 1 
cus, yet those lined with cylindrical epi- 
thelium seem to atf'ord more favorable 
conditions for the parasite than do the 
flat-celled membranes ; and the disease persists more obstinately in the former 
than in the latter — in the uterine cervix, for example, longer than in the vagina. 

While the infection always begins on a mucous surface, it does not 
always remain limited to these : it may spread by continuity to the sub- 
mucous tissues, by the lymph-stream to the nearest lymph-nodes ; it 
may enter the blood-current and produce metastatic infections in distant 
structures — serous membranes and fibrous tissues of joints, bursse, ten- 
don- and muscle-sheaths, pleura, peritoneum, meninges, peri- and en- 
docardium — constituting a veritable pycemia analogous to that Avhich 
follows wound-infections. 

The many follicles and pockets which line the genital canal of either 
sex are naturally included in the bacterial invasion : in the male, the 
numerous lacunse of the urethra, Cowper's glands, the prostatic utricle 
and glands ; in the female, the lacunse of the urethra and urethro-vag- 
inal septum and the vulvo-vaginal glands. 

171 



Gonococci in fresh gonorrhceal pu 
(Frankel and Pfeiffer). 



X 1000 



172 SURGICAL DISEASES. 

This is a fact of great clinical importance, for long after the general 
.surface has recovered its normal condition and the patient is apparently 
well, the gonorrhoeal infection may persist in some of the hidden pock- 
ets in quantity sufficient to infect a partner in the sexual act, and even, 
when favored by alcoholic or sexual excess, to reinfect the genital 
canal of the individual himself. 

The serous and fibrous structures which may become the seat of 
metastatic infection through the blood-current exhibit all grades of 
reaction, from serous hypereemia to purulent inflammation, the effect 
depending, in part at least, upon the varieties of bacteria concerned in 
the process. 

Diagnosis. — Until the discovery of the gonococcus in 1879 there 
was no distinctive feature by which a gonorrhoeal infection could be dis- 
tinguished from other purulent inflammation of the genital tract ; hence 
there occurred many errors in diagnosis, and by consequence many false 
conclusions as to therapeutics. 

When, however, a profuse purulent discharge presents large num- 
bers of gonococci enclosed in both pus and epithelial cells, we are war- 
ranted in a diagnosis of gonorrhoeal infection. In practice, it is only 
the slight, chronic gonorrhoeal discharges, containing but few gonococci, 
which can be confounded with the non-gonorrhoeal discharge containing 
the pseudo-gonococci ; and since cases of chronic gonorrhoea or gleet are 
exceedingly numerous, and cases of non-gonorrhoeal urethritis exhibiting 
the pseudo-gonococci are quite rare, the detection of the characteristic dip- 
lococcus furnishes a very strong presumption of gonorrhoeal infection, 
even when the discharge is slight and the cocci few. 

The clinical distinction between gonorrhoea and other purulent inflammations 
of the genital tract is even less trustworthy : it is true that an acute urethritis, 
beginning from three to seven days after suspicious connection in one who has for 
a long time had no urethral disease may safely be pronounced gonorrhoea ; but 
there are numerous cases of urethritis which do not conform to these conditions, 
and in which the clinical diagnosis can be only a probability. 

In practice, the differentiation of the gonorrhoeal from other purulent 
inflammations of the genital tract must often rest upon both clinical and 
microscopical evidence. AVe may divide all such inflammations in the 
male into four classes : 

1. Gonorrhoeal infection from without, marked clinically by an 
incubation of three to seven days (usually), and a severe inflammatory 
reaction in a patient previously free from urethritis : the microscope 
shows an abundance of gonococci contained in both pus and epithelial 
cells. 

2. Gonorrhoeal infection from -within {auto-infection, the "bastard 
clap " of the older authors), marked clinically by an incubation of six to 
twenty-four hours, and slight or no pain, in a patient with a history of 
uncured urethritis, as shown by slight gleety discharge, gumming of the 
meatus, or merely pus-threads in the urine ; the microscope shows gono- 
cocci, but less numerous than in the first class of cases. 

These two classes include over 90 per cent, of all cases of purulent 
urethritis in the male. 

3. Non-g-onorrhceal infection from without, beginning within 
twenty-four hours after connection, with slight inflammatory reaction, 



GONORRHOEA AND ITS SEQUELM 173 

in a patient previously free from urethritis : the microscope shows no 
gonococci, or at most a few, with an abundance of pus-bacteria. Such 
cases occur especially after excesses in alcohol and venery with a woman 
suffering from leucorrhcea, notably when at or near her menstrual 
period. 

4. Non-gonorrhceal infection from within. — This may be an 
extension to the anterior urethra of an inflammation in the bladder or 
prostate due to vesical calculus, enlarged prostate, gout, or other cause. 
It is not rare in elderly men suffering from these complaints, and is of 
mild degree ; no gonococci are visible. 

In this category one must classify cases of urethritis from injury, 
as by urethral instruments ; from caustic injections for the prevention of 
gonorrhoea, etc., in which the history plainly indicates the cause. The 
possibility that a mild urethritis following connection may be due to an 
urethral chancre should never be forgotten ; the diagnosis is made by 
inspecting the fossa navicularis. 

Conditions favoring 1 Infection. — It is certain that not every sexual 
act with an infected woman conveys the infection, for it is repeatedly 
observed that of several men who cohabit with the same woman in the 
same night, one will acquire, another escape, the disease. To this result 
doubtless several factors contribute : the natural susceptibility of different 
urethras must vary, some having greater natural immunity, some having 
acquired such immunity by repeated infections with the gonococcus. 
Moreover, influences which depress the vitality of the urethral tissues, 
such as excessive drinking, favor infection ; and prolonged sexual excite- 
ment, by which the naturally acid fluids of the urethra are rendered alka- 
line, must have the same effect, because the gonococcus grows well in 
alkaline, poorly in acid, media. A profuse and acrid leucorrhcea of the 
female, especially when heightened by the congestion incident to men- 
struation, must similarly favor the transfer of infectious material. 

The prevention of gonorrhceal infection after exposure is impos- 
sible. Thorough washing of the parts and immediate urination doubt- 
less contribute to that end, but are often ineffectual. 

The use of caustic injections after the act is to be condemned: they may be 
relied upon not to remove nor destroy the infectious material, but to irritate 'the 
epithelial lining of the urethra, and thus pave the way. for bacterial growth. 

The popular belief that a true gonorrhoea can be acquired from a non-gonor- 
rhceal leucorrhcea or menstrual discharge, or from a "strain," is erroneous; while 
it is doubtless true that a simple and brief urethritis can be so acquired. Gonor- 
rhoea in a patient proves the pre-existence of the disease in another person and the 
transfer of infected matter. 

The disease is occasionally transferred without sexual contact, by means 
of infected towels, syringes, urethral instruments, etc. The patient 
should be warned to protect his oivn eyes, as well as the persons of others, . 
from such accident ; and the physician should be most careful to sterilize 
all urethral and vaginal instruments after each use of them, particularly 
upon a case of even suspected gonorrhoea. 

Clinical History. — During a period of incubation varying from 
two to fourteen (usually three to five) days after exposure no evidence 
of disease attracts the patient's attention : then an itching sensation a 
swelling, reddening, and gumming of the meatus, and a smarting pain 



174 SURGICAL DISEASES. 

during urination, are observed, soon followed by the appearance of thick 
pus ; these features become rapidly intensified, until in a few days the 
severe inflammation extending along the penile urethra is manifested by 
great swelling of the meatus, oedema of the prepuce, redness, often 
excoriation of the glans, heat and soreness of the entire penis, and a 
constant discharge of thick yellow or greenish pus. During this period 
the passage of urine causes acute pain ; the stream issuing from the 
meatus is small, twisted, or scattering. As the inflamed tissues sur- 
rounding the urethra are less distensible than normal, erections — which 
are apt to be frequent — are exceedingly painful and often distorted, the 
penis presenting a more or less sharp curve whose concavity is usually 
downward, sometimes also laterally : this is the condition called chordee. 
There is usually a slight rise of the body-temperature. Seminal emis- 
sions during sleep are increased in frequency. 

This condition persists, if untreated, for ten to fifteen days, when the 
symptoms gradually subside : the purulent discharge may persist for 
several weeks after pain and soreness have ceased. 

These extensions are designated by the name of the tissue or organ 
invaded : the infection may attack the entire genital canal, the urinary 
tract, the peritoneum where contiguous to these, and the blood-current 
itself. These will be considered in natural sequence. 

Balanitis, an extension of the infection to the glans penis, often 
occurs in slight degree. In exceptional cases, especially where cleanli- 
ness is neglected or impossible because of phimosis, a severe infection 
of the glans and corona occurs, causing extensive erosions, even ulcera- 
tions. 

Folliculitis, extension of the infection to the lacunas and follicles 
branching off from the urethral canal, always occurs ; but so long as 
the pus produced in these follicles is freely discharged into the iirethra 
no distinct clinical phenomena are induced. If, however, the orifice 
becomes occluded, the follicle becomes distended with pus : when located 
near the fossa navicularis these distended follicles protrude on the exter- 
nal surface, on one or both sides of the frenum, as hard, tender nodules 
as large as buckshot. In a few days these usually soften, discharge 
externally, and heal spontaneously : sometimes they discharge internally 
into the urethra, and exceptionally in both directions, making a urinary 
fistula that it may be difficult to close. 

Periurethral Inflammation. — When, however, these inflamed and 
distended follicles are located behind the fossa, the course of events is 
not always so simple : while the follicle may discharge externally with- 
out complications, yet the inflammation may involve the periurethral 
tissues, making a hard, distinct tumor as large as a hazelnut. This may 
remain unchanged for months, or it may become the seat of a rapidly- 
spreading suppuration : the pus sometimes empties into the urethral 
canal, sometimes rapidly infiltrates the spongy or cavernous bodies. In 
either case the urine may escape into the periurethral tissues, causing the 
so-called urinary infiltration : abscess and fistula, septic phlebitis, em- 
bolism, and pysemia, are all possible unless incision and drainage of the 
infiltrated tissues be promptly made. 

These processes destroy more or less of the normal periurethral 
tissues : the cicatrix by which they are ultimately replaced may later 



GONORRHCEA AND ITS SEQUEL JE. 175 

constitute a stubborn stricture, and even occasion a notable deflection of 
the penis from its normal straightness during erection. 

The clinical signs of diffuse periurethral inflammation are those of septic infec- 
tion in general : pain at the site of the inflamed follicle, at first dull, then acute 
and aggravated during urination and erection : diffuse suppuration and urinary 
extravasation (the latter usually follows soon upon the former) cause throbbing 
pain, a dark-red oedema, chills, and high fever. 

Cowperitis is the designation given to the same process occurring in 
the two large follicles (glands of Cowper or Mery) which are situated 
between the layers of the triangular ligament in the perineum and open 
into the membranous urethra. It occurs after the tenth day of the dis- 
ease, and occasions a tense, painful swelling in the perineum, noticed 
especially by the patient when sitting. In all respects, except the 
anatomical surroundings, it is identical with folliculitis of the anterior 
urethra. 

Prostatitis. — The prostatic urethra is provided with thirty or more 
glands or follicles, besides the relatively large follicle termed the utricle, 
or masculine uterus. When the gonorrheal infection invades this portion 
of the urethra (causing the so-called deep urethritis), these numerous fol- 
licles are invaded by the gonococcus ; and there may result a peri- 
urethral inflammation and suppuration, just as in the anterior urethra. 
This process is in this locality called prostatitis. Periurethral suppura- 
tion and infiltration of urine may occur, the pus and urine burrowing 
into the pelvic connective tissue or the perineum, and the abscess point- 
ing into the rectum, suprapubic space, or perineum. 

Septic infection from the prostatic urethra is especially prone to cause phle- 
bitis, peritonitis, and pyaemia. Fortunately, folliculitis of the deep urethra or 
prostatitis usually terminates by spontaneous evacuation of the pus into the 
urethral canal. 

Deep Urethritis. — In a majority of cases of gonorrhoea the infection 
extends in the second or third week through the membranous and pros- 
tatic urethra to the bladder. This extension is usually indicated by 
distinct symptoms which proceed from the irritation of the prostatic 
urethra. Normally, this portion of the urethra exhibits a triple func- 
tion : in it originates the impulse to urinate ; it is intimately concerned 
in erection and seminal ejaculation ; and it is a sphincter of the bladder. 
Hence the disturbance of its tissues by the gonorrhceal infection causes 
three notable symptoms : (1) increased frequency in the desire to urinate; 
(2) prolonged erections and frequent emissions ; and (3) marked difficulty 
in expelling the urine, sometimes amounting to complete retention, com- 
pelling the use of the catheter. A dull pain, a sense of heat and weight 
in the perineum, rectum, and suprapubic region, and a sharp pain at 
the end of urination and referred to the glans penis, accompany all 
but the mildest cases. The last urine evacuated is apt to be mixed with 
blood, varying in quantity from a few drops to a light hemorrhage. 

Ampullitis and Vesiculitis. — The extension of the inflammation to 
the dilated extremity of the vas deferens (ampulla) and the seminal 
vesicle occurs in a percentage of cases as yet imperfectly determined, 
but probably almost as often as deep urethritis ; for the clinical distinc- 
tion between the latter and vesiculitis has not always been made. The 
chief symptoms marking the extension from the prostatic urethra to the 



176 SURGICAL DISEASES. 

seminal tubes are the pronounced heat and pain in the rectum and the 
large admixture of blood and pus with the seminal discharge. The 
examiner's finger, introduced into the rectum, easily recognizes the 
swollen, tense, and tender vesicles above the prostate. 

Epididymitis and Orchitis. — The further extension of the gonor- 
rhoeal infection along the vas deferens finally involves the epididymis, 
and sometimes the tubules of the adjacent testicle itself. Epididymitis 
occurs in from 5 to 20 per cent, of cases of gonorrhoea, rarely appearing 
before the third week. The first symptoms noticed may be increased 
frequency of urination, then pain and tenderness either in the testicle 
or at the external inguinal ring. Sometimes a chill and fever usher in 
the local swelling ; in a day or two the epididymis has become swollen, 
tender, and exceedingly painful, the skin covering it dark-red and 
oedematous : the testis usually participates in the swelling and pain. 

All these symptoms begin to recede in four or five days, and subside in two 
weeks, except that hard, sensitive nodules may remain in the epididymis for many 
weeks, even months. In exceptional cases suppuration and local necrosis occur in 
the epididymis and testicle. 

Cystitis of gonorrhceal origin is usually limited to the vicinity of the 
vesico-urethral orifice : many cases so called because of the frequency and 
pain in urination, are really instances of prostatitis and deep urethritis. 

Ureteritis, pyelitis, and suppurative nephritis are infrequent 
extensions of the gonorrhceal infection : they are marked by chills, 
fever, and pain, referred to the region of the kidney, the course of the 
ureter, the testicle, and the thigh. An enlargement of the kidney is often 
perceptible. The pus passed with the urine is greatly augmented, and 
there is more albumen than the pus accounts for. 

Lymphangitis and Adenitis. — The lymphatics surrounding the 
urethra are always invaded by the gonorrhceal bacteria, and some of the 
inguinal nodes are usually slightly swollen and sensitive ; in the severer 
cases a lymphatic vessel along the dorsum of the penis is perceptible as 
a hard, sensitive cord leading to the inguinal nodes, which are distinctly 
swollen, and in exceptional instances suppurate (suppurating gonor- 
rhceal bubo). 

CEdema of the prepuce is frequent in the first week of the urethri- 
tis, subsiding as the more acute symptoms lapse : sometimes the oedema 
is so great as to constitute a veritable phimosis, or, if the patient retracts 
the swollen foreskin, he may be unable to return it, presenting the con- 
dition called paraphimosis. The latter is an unpleasant complication, 
because the narrow orifice of the retracted prepuce so constricts the 
penis as to cause great oedema of the glans, and in occasional instances 
—fortunately, rare — extensive necrosis and sloughing in front of the con- 
stricting ring. Usually, however, this ring itself sloughs awav, the strang- 
ulation of the glans is relieved, and the swelling gradually 'subsides. 

Post-gonorrhceal arthritis, often miscalled gonorrhceal rheuma- 
tism, occurs in only 2 or 3 per cent, of cases of gonorrhoea, and is caused 
by the infection of various tissues by means of the blood-current. It begins 
at any time, from three days to three months after urethral infection 
many cases starting in the first month. It affects especially fibrous struct- 
ures and serous membranes, and exhibits an acute variety— beginning with 
chill, fever, and local swelling— and a chronic form, which may be 



GONORRHCEA AND ITS SEQUELM. 177 

primary or a continuation of the acute. It attacks most frequently the 
knee-, ankle-, hip-, shoulder-, and elbow-joints and those of the fingers 
and toes ; sometimes only one joint is atfected, sometimes several are 
simultaneously or successively involved. The local inflammation lasts 
in acute cases two to three months, in chronic cases several years. 

Besides the joints, bursa and tendon-sheaths are often attacked, especially those 
of the legs, feet, and hands ; the muscles of the neck, the conjunctiva, and iris 
also become the seat of the infection. The meninges, peri- and endocardium some- 
times participate in the disease, which is then apt to terminate fatally. 

The morbid anatomy presents nothing distinctive from lesions of the same 
structures due to other causes, except that the gonococcus is sometimes found in 
the inflammatory exudate, especially on serous surfaces. 

Pysemia. — As the gonorrhceal infection includes the pus-microbes as 
well as the gonococcus, we can understand that a real pyaemia, differing 
in no respect from that proceeding from a septic wound, may follow a 
gonorrheal urethritis. Such is really the case, though, fortunately, in 
rare instances. 

Treatment.— The rational treatment of gonorrhoea — the destruc- 
tion of the invading bacteria — is as yet undiscovered : it should be dis- 
tinctly understood that our treatment of the disease is only palliative, 
and that the infection may steadily advance and long persist in spite of 
any treatment. 

An enumeration of the numerous remedies and methods which have been from 
time to time recommended, and of the many specifics and sure-cures even now 
current, would fill this volume : only the measures sanctioned by large experience 
will be here mentioned. 

Anterior Urethritis. — The patient presenting himself with a recent 
gonorrhoea should be first carefully instructed as follows : He should 
scrupulously avoid constipation, bodily activity, alcohol, and sexual 
excitement ; he should destroy or sterilize by boiling all clothes and 
handkerchiefs soiled by the discharge, and should wash his hands im- 
mediately after every contact with the infected parts or dressings ; he 
should not protect his linen by inserting a wad of cotton under the fore- 
skin (as most Gentiles do), because the cotton dams up the pus in the 
urethra and spreads it over the glans penis ; he should indulge sparingly 
in meats, coffee, and tobacco, and should keep the horizontal position as 
much as possible. He should procure a gonorrhoea-bag — a cloth or 
rubber sack which encloses the penis and is secured by tapes around the 
waist — or make a substitute by sewing tapes to the toe of a stocking, 
and place some absorbent cotton in the bottom ; in this way the linen 
is protected, while the pus drains freely from the urethra. 

Medicinal treatment is internal and local ; the former consists 
of — (1) Laxatives, especially calomel and salines ; these are beneficial in 
all cases, and imperative when there is a tendency to constipation, which 
must be carefully avoided ; 

2. Balsams excreted by the kidneys, such as santal oil, freshly 
powdered cubebs, and copaiba. Of these pure santal oil is decidedly 
the most valuable. 

Freshly powdered cubebs, a teaspoonful every two to four hours, 
markedly lessens the amount of discharge, though frequently disturbing 
the stomach ; the oleoresin of copaiba, a ten-minim capsule six times a 

12 



178 SURGICAL DISEASES. 

day, has a slighter influence upon the discharge, but a greater effect 
upon the stomach, and occasionally produces an annoying scarlet rash. 

Internal antiseptics, so called, such as salol, which when given by the mouth 
are excreted by the kidneys as carbolic and salicylic acids, etc., have failed to pro- 
duce the beneficial effect hoped from them, and have been abandoned, though 
there is still a lingering belief that boric acid, in doses of three to five grains four 
times daily, does exert a good influence. 

3. Diuretics. — Water, milk, potassium acetate and bitartrate are use- 
ful to dilute the urine and thereby diminish the irritation of the inflamed 
urethra by contact of this fluid. 

Internal medication may therefore be outlined as follows : calomel in 
quarter-grain doses, three to six a day for one or two days ; for the 
next six days a half teaspoonful of potassium bitartrate and five grains 
of sodium phosphate in a glass of hot water, night and morning ; after 
which the calomel may be repeated. Naturally, the size and frequency 
of these doses must be determined by the effect produced. 

Twenty minims of good savtal oil or a teaspoonful of fresh cubebs 
may be given from four to eight times daily as the stomach permits. 

The local treatment of gonorrhceal urethritis is exceedingly important : 
the ancient prejudice against it, based upon the ill effects of severe and 
caustic injections, does not hold against the later methods. 

Of all local remedies, hot water holds the first place, and cannot be 
used too freely nor too often : it should be applied to both the exterior 
and interior of the penis. This organ should be immersed, as often and 
as long as circumstances permit, in a glassful of water whose tempera- 
ture may be at first 100° F., and is gradually raised by the addition of 
hotter water to 105°, 110°, or 115° F. At intervals injections of the 
same water should be thrown into the urethra. The addition of boric 
acid to the water, a teaspoonful to the pint, enhances the moral, and 
possibly the physical effect of the water. 

Injections into the urethra should be made with a hard-rubber syri?ige holding 
half an ounce and terminating in a blunt tip without nozzle ; and it is wise 
for the physician to instruct the patient how to inject, both verbally and by 
administering an injection, and causing the patient to repeat the process in the 
doctor's presence. Before an injection the patient should empty the bladder: the 
syringe, filled with hot water (100° F. or more), is held in the right hand, the tip 
placed carefully between the lips of the meatus, which are then gently compressed 
laterally by the thumb and fingers of the left hand ; by the right hand the piston 
is pressed slowly and gently home until the urethra feels distended. The syringe 
is then removed, the escape of the water being prevented by compression of the 
meatus. After a half minute the water is allowed to escape, and a second injection 
of hotter water (105° to 110°) is made. After this one of the following solutions 
is injected : hydrastin muriate, saturated solution, or zinc permanganate, 1 : 4000 
(1 grain to 8 ounces of water). 

It is understood that the hot-water injections are continued. The 
hydrastin is not irritating, and presents only one disadvantage — the yel- 
low color, which, however, is easily removed by water. These injections 
should be made from six to ten times per day. 

Under such treatment the acute symptoms commonly subside in a 
week, and in two weeks the discharge becomes slight in quantity and 
resembles thin milk. When this occurs the hot-water immersions are 
discontinued and zinc-chloride solution, one-half grain to six ounces, sub- 
stituted for the permanganate. 



GONOERHCEA AND ITS SEQUELAE. 179 

Various plans have been practised for the purpose of aborting a 
gonorrhoea : these may all be dismissed as certainly useless and often 
dangerous. 

Under such treatment as has been outlined perhaps one-third of the 
cases of acute gonorrhoea are apparently cured in from three to six weeks ; 
but it should be impressed upon the patient that the cessation of free 
discharge from the meatus does not prove that he has recovered ; for 
long after this stoppage of the flow there may persist various evidences 
of disease, such as a gumming together of the lips of the meatus, espe- 
cially during the night ; the appearance of a milky drop at the meatus 
in the morning ; and the constant presence in the urine of thick white 
threads (clap-threads) of pus, which soon sink to the bottom of the 
vessel (these are commonly called by the German name, tripper-fdden). 
The persistence of any of these phenomena indicates the presence of 
one or more infected areas in some portion of the genital canal, and the 
case must be considered one of chronic gonorrhoea. 

Chord.ee is not frequent under the hot-water treatment : if it occur, 
an attempt to prevent it may be made by the administration at bedtime 
of thirty grains of sodium bromide or two grains of camphor monobromide 
with a grain of eodeia. When awakened by the painful erection, the 
patient should empty the bladder and apply cold water or a cold metallic 
object to the penis and perineum. Constipation favors chordee. 

Balanitis may be controlled by hot applications of boric-acid solution, 
followed by vaseline inunctions. 

Phimosis is reduced by immersions in hot water and injections of 
the same under the foreskin. 

Paraphimosis needs no treatment but hot water, unless the swelling 
of the glans seems to threaten necrosis of tissue : in this case the end 
of a probe-pointed bistoury should be inserted under the constricting 
band, which is then divided, the incision being dressed with iodoform or 
aristol. 

Folliculitis in the penis needs no special attention unless symptoms 
of periurethral suppuration become apparent — local redness, tenderness, 
and boggy swelling : in such case incision and perfect drainage should 
be promptly made, followed by hot-water immersions of the septic 
tissues. 

Periurethral suppuration, occurring in any portion of the tract from 
meatus to bladder, must be recognized early and treated promptly, for 
it is apt to be followed by urinary infiltration and the severest forms of 
septic infection. When discovered, whether in penis, perineum, or pros- 
tate, the pus should be promptly evacuated from the nearest cutaneous 
surface. 

Deep urethritis occurs in the majority of cases of gonorrhoea, and 
often requires no especial treatment ; indeed, it is often unnoticed by 
both patient and physician. In more severe cases, when frequent and 
difficult urination, pain in perineum and rectum, and some fever attract 
attention, the patient should remain in bed, take frequent hot-water 
fomentations, hip-baths, and enemata ; the perineum should be irritated 
by mustard plasters or even blistered by cantharidal collodion ; and the 
pain and straining to urinate, often agonizing, quieted by morphine ; 
complete retention of urine, requiring the use of the catheter, is not 



180 SURGICAL DISEASES. 

unusual. Not infrequently these severe symptoms are suddenly relieved 
by a discharge of pus from the prostatic follicles into the urethra ; but 
occasionally the pus burrows into the perineum, vesico-rectal or supra- 
pubic tissue, requiring prompt evacuation. 

Vesiculitis and ampullitis often follow closely upon deep urethritis, 
from which they can be distinguished by the finger in the rectum, reveal- 
ing an oblong, tender swelling on one or both sides above the prostate. 
Rest in bed, hot hip-baths, and enemata, and morphine should be used 
until the more acute symptoms subside ; then with a finger in the rectum 
gentle pressure toward the prostate should be made. Sometimes this 
manipulation is rewarded by a gush of foul pus through the urethra and 
meatus, and rapid subsidence of both swelling and symptoms. If, how- 
ever, the effect fails and the symptoms increase in severity, an incision 
should be made into the sac from the rectum, the cavity washed out and 
lightly packed with gauze. 

Epididymitis can usually be aborted by painting the skin along the 
cord and epididymis with guaiacol, using fifteen to thirty minims for each 
application, and making three applications in the first twenty-four hours, 
and two each day thereafter for a few days. The skin is usually peeled 
by the guaiacol, and the excoriations should be dressed with vaselin. 

Both testicles should be held up against the symphysis in the following manner: 
The entire scrotum is enveloped in a thick layer of cotton, which is covered with 
oiled silk or sheet rubber, surrounded by a gauze bandage, and the whole raised 
and supported against the symphysis by a jockey-strap or a silk handkerchief 
pinned to the underwear. The cotton should be changed every day. By the early 
use of guiacol and this bandage confinement to bed can usually be avoided : under 
other treatment a week's rest in bed is commonly inevitable. 

Orchitis. — A certain amount of orchitis usually accompanies epidid- 
ymitis, and is relieved by the treatment for the latter : the local appli- 
cation of guaiacol may be extended over the testicle if this organ is 
swollen. 

Post-gonorrhceal arthritis, or gonorrhceal rheumatism, has until 
recently been unaffected by any of the numerous remedies tried upon it : 
treatment has consisted of wrapping the inflamed joints in cotton and 
oiled silk, placing the patient upon a water-bed and administering ano- 
dynes. Inunction of the inflamed joints and tissues with guaiacol (not 
more than two drachms being applied per day) promises better than any 
medication hitherto advised. 

Chronic Gonorrhoea; Gleet. 

By common consent, a gonorrhoeal infection of the genital tract in 
the male which persists more than eight weeks is termed a chronic gon- 
orrhoea, and the discharge from the meatus, when present, is called a 
gleet. 

It has been customary to consider chronic gonorrhoea and gleet syn- 
onymous terms, but this is one of the many errors which have descended 
to us from the earlier surgeons ; for by a gleet we understand a discharge 
from the meatus, but the gonorrhoeal infection often persists in the pros- 
tatic urethra and seminal tubes long after the anterior urethra is prac- 
tically well and without any discharge from the meatus ; for the pus 
produced in the deeper parts may be prevented from reaching the ante- 



GONORRHOEA AND ITS' SEQUEL JE. 181 

rior urethra by the cut-off muscle. Hence a chronic gonorrhoea may- 
long exist without a gleet — an important clinical distinction. 

Gleet is the continuation of a gonorrheal discharge from the meatus, 
and may vary from a 'profuse milky to a slight watery flow. Sometimes 
there will during the day be no distinct discharge, but only a gumming 
of the meatus ; but in the morning, with or without milking the penis, a 
drop or two of milky fluid appears, the so-called morning drop, or, as 
the French call it, the military drop. 

The first step toward the intelligent treatment of gleet is therefore 
the discovery of the infected area, which may be found anywhere from 
the meatus to the vas deferens. For practical diagnosis and treatment 
the genital surfaces may be divided into three portions : (1) the anterior 
urethra (to the bulbo-membranous junction) ; (2) the deep urethra (from 
bulb to bladder) ; and (3) the prostate, ampullae, and seminal vesicles. 

It is chiefly important to know whether the pus-production is limited 
to the anterior urethra or extends also to the deep urethra : in the latter 
case some involvement of the prostate and seminal tubes may be 
expected. 

Persistence of suppuration is due to the existence of diseased areas, 
which are of three classes: (1) plastic exudate in the submucous tissue, 
causing a catarrh of the surface and developing into stricture ; (2) pre- 
existing stricture ; (3) imperfect drainage, as in the prostatic follicles and 
seminal vesicles. 

The anterior urethra is explored by — (1) bulbous sounds and (2) 
the urethroscope (endoscope). 

The bulbous sound (Fig. 39) is so shaped as to detect a lack of normal disten- 
sibility of the canal ; that is, a stricture. This natural distensibility (calibre) varies 
in different portions of the urethra, being greatest in the bulb and the prostate and 

Fig. 39. 



Bulbous sound. 

least at the meatus, the scrotal and membranous portions. The calibre also varies 
in different individuals, maintaining a fairly constant ratio (about four-tenths) to 
the circumference of the flaccid penis : in general it ranges from 30 to 36 of the 
French scale. By means of the bulbous sounds any strictures worthy of note can 
be detected, provided the meatus will admit a bulb of full size. If, as often hap- 
pens, the natural contraction of the meatus prevents a satisfactory exploration by 
these instruments, the surgeon must either divide the meatus to 35 Fr. or employ 
an Otis (or similar) urethrometer. Division of the meatus should never be per- 
formed if that orifice admits a 22 Fr. bulb ; for, while the operation is trivial, the 
result is a gaping deformity of the natural nozzle-shaped orifice, whereby the 
expulsion of urine and semen is unfavorably influenced, and the patient's liability 
to gonorrhoea and urethral chancre undoubtedly increased. 

Fjg. 40. 




opt*. 
Urethrometer. 



Instead of cutting a normal meatus, the surgeon should use the urethroinet'^r 
of Otis (Fig. 40), an ingenious instrument constructed on the umbrella principle. 



182 SUROICAL DISEASES. 

introduced when closed, it is dilated by a screw at the handle to the desired size 
(33 Fr. or more), and then drawn forward, the variations in calibre necessary tor 
its passage being indicated on the dial. 

Neither bulbous sounds nor urethrometer should be passed into the 
muscular portion of the urethra beyond the bulb : the distensibility of 
this portion of the canal is tested by cylindrical sounds. 

The prostatic urethra is practically never the site of contractions (stric- 
tures) as the result of gonorrhoea. 

Inspection of the entire urethral surface can be made through one of the many 
urethroscopes in use : by it the surgeon may detect diseased areas by the unnatural 
redness and granular appearance of the surface. While urethroscopic inspection 
is always desirable in cases of gleet, it is not always essential. 

Digital examination per rectum should never be neglected in deter- 
mining the source of a gleety discharge, even though the anterior urethra 
is found to be strictured or otherwise diseased ; for the prostate and 
seminal vesicles are often the seat of persistent infection and contribute 
to the discharge. 

To determine the condition of these parts the surgeon's fore finger- 
best enclosed in a rubber condom which is anointed with glycerin — is 
introduced into the rectum of the patient, who may either lie upon his 
back or stand with the feet apart and body bent forward. The finger 
first determines whether the prostate is swollen, asymmetrical,, or unduly 
sensitive ; then the finger-tip is made to " milk " the prostatic follicles by 
gentle pressure on the organ from above downward (toward the anus) : 
the prostatic utricle, which lies between the lateral lobes of the organ, 
and is often distended with pus, should be included in the milking pro- 
cess. The appearance of a purulent discharge at the meatus during this 
manipulation shows that the prostatic follicles are diseased. 

The finger should then be inserted farther into the rectum, so as to 
compress or " milk " the seminal tube and vesicle on each side : the escape 
of pus and catarrhal products in notable quantity indicates that these 
tubes are implicated in the chronic infection. 

Treatment of Chronic Gonorrhoea and Gleet. — The treat- 
ment of gleet should always be preceded by a determination of the seat 
of the disease, as already outlined : a routine prescription of injections 
or use of sounds, while curing a certain number, will fail to relieve 
many that are amenable to intelligent treatment. 

Certain general measures are applicable to all cases of gleet : they 
should carefully avoid constipation, alcohol, and sexual excitement. 

It may be here remarked that instances are not rare in which an obstinate 
gleet has stopped suddenly and permanently after indulgence in beer or wine by a 
patient who has long abstained, or after sexual intercourse by a man who has long 
been continent. 

Patients afflicted with gleet should drink plenty of good water and 
avoid the excessive use of tobacco and coffee. 

The special measures required are — (1) sounds ; (2) injections — ante- 
rior and deep urethra ; (3) milking of prostate and seminal tubes ; (4) 
medicines internally and locally ; (5) local applications to diseased patches 
through the endoscope. 

(1) Sounds. — A stricture should be treated by gradual dilatation car- 
ried to the full calibre of the urethra, 32 to 3G Fr. If a narrow meatus 



GONORRHCEA AND ITS SEQUELjE. 183 

prevents the use of large sounds, the surgeon should choose between 
enlargement of the meatus (advisable in exceptional cases only) and 
dilatation by means of special instruments, the dilators of Otis, Tuttle, 



Fig. 41. 




Otis' dilating urethotome. 

Oberlander, etc. Even when no decided stricture is detected, the passage 
of large sounds through the deep as well as the anterior urethra is an 
advisable accessory to other treatment. The surgeon who possesses one 
of the special dilators should gradually overstretch (by 2 or 3 mm.) any 
contracted ring. 

(2) Injections. — Of the multitude of injections recommended for 
gleet of the anterior urethra the following are useful : hot water (100° to 
115° F.) alone and containing in solution hydrastin muriate (saturated) 
or picric acid, zinc permanganate, nitrate of silver, one grain to eight 
ounces : alcohol is an old and valuable remedy, beginning with one part 
in twenty of water, and gradually increasing to one part in five. 

Deep Injections. — Liquids injected from the meatus do not ordi- 
narily reach the deep urethra, because arrested by the " cut-off" muscle. 
Injections into the deep urethra are therefore usually made through a 
tube introduced beyond the bulbo-membranous junction. 

Special syringes for this purpose have been designed by Guyon, Ultzmann, 
Keyes, and others (Fig. 42), whereby an exact number of minims of a given strong 

Fig. 42. 




Deep urethral syringe. 

solution can be deposited in the deep urethra — a process often called instillation. 
A better practice is irrigation of the deep urethra with a larger quantity of a weaker 
solution. For this purpose a small soft catheter (sterilized) is introduced until the 
urine flows, then withdrawn about an inch and a half, and a five-ounce rubber 
syringe or small fountain syringe (hung low) attached. The solution passes into 
the deep urethra, and thence into the bladder, the cut-off muscle preventing its 
escape through the penis ; the catheter is then withdrawn and the patient empties 
the bladder, thus passing the solution a second time over the deep urethra. 

The solution used should be hot (100° F.), and may consist of nitrate of silver, 
one part to ten thousand of water, bichloride of mercury, one to twenty thousand, or 
permanganate of potassium, one to five thousand, employed every two or three davs. 

Many patients can with practice inject the bladder without a catheter : 
this is, when practicable, preferable to the injection by catheter, and is 
accomplished by placing the patient in a reclining position, with thighs 
flexed upon the body. A fluid gently injected by means of a five-ounce 



184 SURGICAL DISEASES. 

syringe may, after slight delay at the cut-off muscle, flow into the blad- 
der. Elderly men are especially favorable subjects for such injection. 

(3) Milking- the prostate and seminal vesicles is always required 
when these parts are obviously diseased, and, like the passage of sounds, 
is sometimes useful even when no infection of these parts is detected. 
This manipulation should be performed at first very gently and for only 
two or three minutes at a time : the pressure used and the time expended 
may be gradually increased, and the intervals between sittings reduced 
from six days to three. If the pain caused persists for several hours, 
the next application should be more moderate, as violent pressure may 
cause an extension of the infection along the vas deferens to the 
epididymis. 

(4) Medicines administered by the mouth cannot be relied upon to 
influence a gleet : the best effects are obtained from turpentine oil in 
three- to five-drop doses, santal oil in ten-minim doses, and tincture can- 
tharides in three-drop doses, four to six times daily. 

Iron and other tonics are beneficial to a patient showing any signs of anaemia, 
and sometimes are quite essential to a cure. 

In the suppository form drugs are applied directly to the prostate and vesicles 
with benefit when these parts are involved : ichthyol, two grains, ext. belladonnse 
or hyoscyami one-quarter grain, may be thus administered three times daily. 
Syphilitics should take mercury or iodine, and scrofulous subjects guaiacol : in 
malarial districts quinine may have a decided effect in checking a gleet. 

(5) Local applications to diseased areas through the urethroscope 
are sometimes necessary : the diseased surface is brought into the field, 
cleansed with cotton, and touched with a stick of copper sulphate or a 
strong (10 to 20 per cent.) solution of silver nitrate, the application 
being repeated every few days as the course of events indicates. 

The treatment of chronic gonorrhoea and gleet may be thus 
summarized : In addition to the hygienic measures necessary for all, 
and the tonic treatment required by some, direct measures should be 
adapted to the part of the genital tract involved : for the anterior 
urethra, sounds, injections, applications through the endoscope ; for the 
deep urethra, irrigations, large sounds ; for the prostate and seminal 
tubes, the treatment for the deep urethra combined with the milking 
process and suppositories. 

When does a chronic gonorrhoea cease to be contagious ? is a 
frequent and most important question, to which we can give no definite 
answer. Theoretically, the contagion ceases when the gonococci dis- 
appear absolutely from the body, but, practically, we cannot determine 
when this happy event occurs in a given case. So long as we find these 
bacteria in a free discharge or even scattered through the pus-threads 
(tripper-fdden), which are passed with the urine long after free discharge 
has ceased, we believe the individual capable of conveying the infection ; 
but we know that the gonococci may lurk in crypts and follicles of the 
genital canal even when a careful search fails to detect them in the pus- 
threads. Under the excitement of intercourse a rapid multiplication 
of these organisms may occur, resulting in the infection of the woman 
and the reinfection of the patient's own urethra. This is especially apt 
to occur in the frequent and prolonged sexual indulgence of recent 
marriage. Gonococci have been found in the pus-threads three and 
four years after the last infection. 



CHAPTEE XII. 

SHOCK AND COLLAPSE. 

By Roswell Paek, M. D. 



Under these two terms, which are nearly interchangeable, is de- 
scribed a condition of reflex depression which occurs often after severe 
injuries or accidents, and often as the result of mental emotions from 
apparently trivial causes. If one is to distinguish between shock and 
collapse, one should reserve the former term for cases which follow 
injury or accident, and the latter for those cases occurring spontaneously 
or from mental or intrinsic causes not connected with physical violence. 
Shock may be of all degrees, from the most temporary faintness from 
which one recovers within a few moments, up to a condition of vital 
depression which terminates fatally, there being no reaction in spite of 
all efforts to produce it. 

Symptoms. — These at least can be referred almost solely to vaso- 
motor paralysis, obviously of reflex origin from the peripheral (i. e. the 
sensory) nerves. They consist of an expressionless face, of pallor of 
the skin and visible mucous membrane, with corresponding coldness of 
the same (7. e. reduction of surface-circulation and heat) ; of dilated 
pupils, reacting slowly to light ; irregularity of the heart's action, with 
a weak, irregular, thready, or imperceptible pulse ; irregular respiration, 
breathing being irregular both in rate and depth ; mental inactivity and 
apathy ; loss of voluntary muscle-movement ; impairment of superficial 
sensibility ; actual reduction of body-temperature ; occasionally nausea 
or actual vomiting. These at least constitute the symptoms in the 
majority of cases, and form what may called the apathetic or torpid type 
of shock. 

Again, we may have shock of the so-called erethistic type (Travers), 
in which patients are restless and excited, uncontrollable, and yet with 
irregular pulse and breathing, often with dilated pupils. Finally, we 
have a third type, described by Travers as the delayed, in which the 
symptoms are as above detailed, but come on only some hours after that 
which has produced them, but which may be only an expression of con- 
cealed (internal) hemorrhage. The delayed type is often seen in those 
who escape serious accident with a minimum of physical harm. 

As shock becomes more pronounced, mental depression deepens into 
coma, or mental excitement subsides into it ; the surface becomes colder 
and bathed with perspiration ; and death follows. These symptoms are 
those generally noted, whether following injury to the head and denot- 
ing so-called concussion of the brain, or loss of blood, or wound of the 
abdomen with injury to the viscera, blows upon the testicles, gunshot 

185 



186 SURGICAL DISEASES. 

wounds, or other accidents which are notorious causes of shock. They 
follow also after perforation of the bowel, as in typhoid fever or appen- 
dicitis, or fatal cases of empyema, or the depression following the receipt 
of bad news, or fright, etc. ; in other words, the physical condition is 
practically the same no matter what the exciting cause. 

Diagnosis. — Shock has practically only to be diagnosed from fat- 
embolism, or possibly from a general and more or less permanent condi- 
tion of physical depression. From the latter it is usually easily disso- 
ciated ; differentiation from the former is not always easy, and it is 
unquestionable that many patients have died of fat-embolism in whom 
the actual cause of death has not been appreciated, yet has been ascribed 
to shock. (See Fat-embolism, Chapter II.) ,' .- ''■ \ 

Shock is sometimes scarcely to be distinguished from other conse- 
quences of exhaustive hemorrhage, such as acute reduction of the normal 
amount of haemoglobin, save by careful estimation of the latter. ( Vide 
Chapter II.) 

Treatment. — The treatment of shock consists in those measures by 
which reaction may be safely brought about. At the very outset one 
must bear in mind two or three cautions that may not safely be neg- 
lected. One is, that it is injudicious to establish reaction too quickly, 
lest it be succeeded by over-action with attendant disasters in the shape 
of secondary hemorrhages, etc. Another is, that, volition being so 
largely destroyed, these patients cannot swallow nor act as they would 
under other circumstances. It is a mistake, then, to expect a patient 
suffering from shock to drink strong liquors, for instance, as would one 
when not so suffering, since a little of the irritating fluid may escape 
into the larynx and set up a violent coughing-fit which, of itself, might 
prove fatal. The same is true of inhalations of strong volatile stimu- 
lants, like ammonia, etc. These measures, therefore, should all be 
resorted to with care and discretion. Cerebral ancemia is evidently a 
part of the condition of shock, and should therefore be combated by a 
dependent position of the head. Hence the patient should be laid flat, 
or even with the head lower than the rest of the body — /. e. the feet and 
extremities raised. It is a good plan occasionally to bandage the extrem- 
ities from their tips toward the body, in order that the blood which they 
would naturally contain may be pressed into needed service in the vital 
organs. Should, however, cyanosis be noticed, it may be held that the 
depression of the head is being overdone. Warm stimulating drinks, if 
they can be swallowed, are always of avail ; and whiskey, brandv, etc. 
should be given dilute and warm rather than strong and cold. External 
heat is evidently indicated, and in many cases can be well applied by 
immersing the patient in a bath-tub of warm water, taking pains only to 
keep the face out of water. When this be not at hand, bottles and other 
receptacles for warm water may be applied about the patient, care being 
exercised not to burn him. Enthusiastic application of too much heat 
under these circumstances has often been the cause of serious burns with 
great resulting discomfort. Artificial respiration may be resorted to, or 
the diaphragm may be stimulated to activity by the Faradic current, 
applied with one pole over the phrenic nerve, the other over the dia- 
phragm. When the stomach does not retain, or when the patient cannot 
swallow stimulating drinks, almost as much benefit can be gained by 



SHOCK AND COLLAPSE. 187 

resorting to enemata of hot black coffee with brandy, with ammonium 
carbonate, etc. Nitrite of amyl will frequently bring a flush to the face, 
and will relieve vasomotor spasm of the cerebral capillaries and of the 
body surface, thus helping to equalize the circulation. It will be found 
sometimes of great value. The principal remedies by which to stimulate 
the activity of the heart are strychnia and tincture of digitalis, both of 
which should be administered subcutaneously and in comparatively large 
doses. A flagging respiration may also be stimulated and sustained by 
atropia, given in the same way. Under these circumstances, when these 
drugs are called for, it would be well to give in one hypodermic injec- 
tion 1 c.c. of tincture of digitalis with -^ of a grain of strychnia and 
Y^-jj- of a grain of atropia. This may be repeated in half an hour or an 
hour if necessary, while the digitalis alone may perhaps be given at more 
frequent intervals. 

The erethistic or extremely restless type of shock may always be 
profitably treated by small, at all events sufficient, doses of opium, pref- 
erably by morphia, -|- to ^ grain subcutaneously, and repeated p. r. n. 

Such a case as this requires most careful and constant watching and judicious 
stimulation, in order that one may stop abruptly when reaction becomes too marked 
or comes on too suddenly. 

When shock is due, in large measure at least, to loss of blood, either by acci- 
dent or operation, the infusion of a saline solution, consisting of sterilized water 
1000, ammonium carbonate 1, common salt 6, may be practised, this fluid being 
slowly introduced through a hollow needle into one of the superficial veins where- 
ever it may be most easily reached. It should not be introduced rapidly, but 
maybe employed very gradually to the extent of 500, 1000, or possibly even 2000, 
c. c. of this fluid. It serves to equalize the circulation and to give to the endocar- 
dium the stimulus which it must get from a certain volume of fluid of normal 
specific gravity in order to excite cardiac motions. A fluid thus prepared and 
used is probably just as efficacious as blood or milk, is much more easily obtained, 
and serves in every respect as well. 

Finally, the question of immediate operation has often to be most 
carefully considered. There can be no question but that shock is often 
alleviated by prompt removal of mutilated limbs or parts whose frag- 
ments, when still connected with the trunk, seem rather to perpetuate 
the condition. So, too, prompt surgical attention to severe compound 
fractures, as of the skull or of the limbs when bone-ends are much dis- 
placed or are projecting, seems to be a most important measure and an 
essential part of the treatment of shock. 



CHAPTER XIII. 

SCURVY AND RICKETS. 
By Roswell Pakk, M. D. 



Scurvy. 



Scurvy is an affection by general consent placed among the so- 
called surgical diseases, manifesting, at all events, many distinctly sur- 
gical features and possibly of parasitic character, although this feature 
of its existence has not as yet been incontrovertibly established. It is 
in large degree a starvation disease, its principal characteristic being 
that of mal-assimilation, accompanied by more or less profound amentia. 
It has certain points of resemblance to that condition of multiple 
neuritis met with in warm climates and known usually as beri-beri. The 
former is apparently due to the absence of a vegetable regimen, while 
beriberi is largely due to the absence of an animal regimen, nature hav- 
ing intended that man's diet should be mixed, and having ordained that 
suffering and disease practically always follow confinement to one or the 
other. 

Pathology. — The pathology of scurvy is very obscure. The con- 
dition is certainly dependent upon chemical alterations in the blood, 
without, however, morphological changes which are distinct or pathog- 
nomonic. The ease with which hemorrhagic effusions occur, the 
degeneration of muscles and other tissues, the frequent detachment of 
cartilages, can, in a general way, be accounted for by conditions thus 
summarized ; for which, however, we have no minute explanation. 
Moreover, scurvy may so complicate various other diseases, and usually 
does when occurring in large bodies of men — as in armies, prisons, 
among convicts, etc. — that it is hard to dissociate morbid phenomena 
and assign to each its proper place. 

Symptoms. — The disease begins by a condition of more or less 
generalized prostration, with an icteric tint of the skin, malaise, mental 
torpor, loss of appetite, insomnia, etc. The first recognizable or dis- 
tinctive local appearances occur about the margins of the gums. Here, 
in the intervals between the teeth, the gums become livid, friable, and 
bleed easily, while the breath assumes a characteristic fetid odor. These 
appearances are followed by local pains, diversified and sometimes ex- 
cessive, and extravasations of blood in the skin and under the visible 
mucous membranes, causing small ecchymoses, which by themselves 
would be considered as simple purpura hsemorrhagica. These pass 
through the usual phases of extravasations, while it is made evident by 
pain, nodular masses, etc. and by post-mortem examination that similar 
hemorrhages occur in the deeper tissues, especially in the muscles, even 
in the bones and epiphyses. So easily, in advanced stages, do hemor- 

188 



SCURVY AND RICKETS. 189 

rhages occur that there is often external bleeding, particularly from the 
gums and mucous membranes, while from points thus involved pyogenic 
infection may proceed internally ; and at last one sees a picture of, as 
it were, an animated corpse, with surface discolored and mottled, often 
appearing terribly bruised, with ulcerations where extravasations have 
failed to resolve, and where infection has occurred, possibly with epiph- 
yses loosened, and, if time permit, necrosis of bones of the extremities. 
In such cases death results from marasmus and sepsis. 

Tbeatment. — So long as the patient be not in the desperate condi- 
tion last described the prognosis and promise of treatment is very good, 
since all the milder manifestations of scurvy can be completely dis- 
sipated by suitable feeding and medication. Loss of teeth and cica- 
trices of ulcers, of course, leave permanent traces, but function can be 
completely restored. So far as the purpura is concerned, it is simply 
one expression of the scorbutic condition. Nearly all cases of scurvy 
will present purpuric manifestations, but by no means all cases of pur- 
pura are necessarily scorbutic. The canons of treatment may be 
summed up in proper diet and in the administration of certain drugs. 
Proper diet should be issued at once, but administered, especially in 
severe cases, with extreme caution. The food selected should be given 
in small quantities, but frequently. It will consist in large measure of 
fresh fruits and vegetables, while cranberries and lime-juice figure 
largely among the former. Buttermilk is excellent, and cider may be 
allowed ; lemonade is also highly commended if it contain not too much 
sugar. 

For the local condition in the mouth an antiseptic mouth-wash con- 
taining a fair proportion of hydrogen dioxide is most advisable. Alco- 
holic stimulants are called for, at least up to a certain point. Strychnia 
and cinchona preparations will give force to the heart's action and the 
horizontal position, for a time at least, will prevent sudden heart- 
failure. The compound syrup of hypophosphites, with the newer meat 
preparations, will supply lacking material, while the hemorrhagic mani- 
festations are best controlled by the fluid extract of ergot and aromatic 
sulphuric acid, separately or combined. 

Of the importance of fresh air, cleanliness, etc. one need scarcely 
speak in this place. 

Rickets. 

Rickets, or rachitis, is another of the diathetic conditions, in this 
instance not yet considered of parasitic origin, met with most commonly 
in infancy and early childhood, although its resulting lesions may per- 
sist throughout life. It is characterized by nutritional disturbances and 
organic irregularities. 

Pathology. — Rickets is spoken of as " foetal " or " congenital " 
according to whether the infant presents characteristic markings at birth 
or whether they develop later. So far as one can see, the most marked 
constitutional defect is in the supply of calcium salt, which leads appa- 
rently to formation of bone which has not enough of compact tissue to 
make it strong. Especially along the line of junction between bone and 
cartilage do we see the most marked expressions of rachitic lesions. 
Here the cartilage is evidently actively growing, while the bone-forma- 



190 SURGICAL DISEASES. 

tion proceeds with difficulty, and the proportion of vascular tissue is 
excessive. The result is prolongations of soft vascular into the carti- 
laginous tissue, by which the latter becomes more or less absorbed and 
ossification is essentially interfered with. In fact, in severe cases it may 
be entirely lacking. In consequence, at epiphyseal lines one may have 
a layer of osteoid tissue which is not cartilage and will not become bone 
Because of its yielding nature, then, it warps under the mechanical 
strain to which the bones of the extremities in young children are con- 
stantly subjected. 

The osseous lesions of rickets differ from those seen in osteomalacia 
in that in the latter the softened tissue is practically decalcified bone, 
while in the former case most of the affected tissue has never got so far 
as genuine bone-formation, but is arrested in its perverted state. 

The result of rickety changes in the skeleton is a thickening of the 
shafts of long bones, of the outer table of flat ones, of the epiphyseal 
extremities of shafts and frequently a stunting of their development, so 
that they do not attain their normal length. The periosteum, having 
much to do with the development of bone, is also affected in rickets, 
with the result that when the changes occur, mostly subperiosteal^, we 
get warpings and curvings of the bone-shafts, while so long as the dis- 
turbance is epiphyseal more or less abrupt curvatures and angular 
deformities will be produced as the result of muscle-action. So marked 
are the changes in some instances that it has been stated that bones may 
even lose three-fourths of the calcium salts which they ought to con- 
tain. When, as is the case, rachitic bones are so soft as to be easily cut 
with a knife, it is not strange that marked deformities occur as the 
result of muscular activity. (Vide Plate X.) 

Thus, in the extremities we get bow-legs, knock-knees, clubbing of the ends of the 
long bones, bending of the neck of the femur, flat-foot, club-foot, etc. ; while the 
clubbing of the bone-ends may be also well marked in the bones of the upper 
extremity, where, however, marked deformity is less common, because the upper 
extremity does not bear the weight of the growing body. In the skull the bones 
remain soft and yielding to pressure, with a tendency to return to their original 
membranous condition, and this is the condition comprised under the term cranio- 
tabes rachitica. The fontanelles always remain open for an undue time ; the sutures 
are broad and membranous. The bones of the face grow less rapidly, giving to the 
face a disproportionately small size; dentition is delayed and the teeth decay very 
easily. The upper incisors often project far over the lower. 

In the thorax we get enlargements of the sternal ends of the ribs, causing a row 
of nodules spoken of as the rachitic rosary. The ribs tend to sink in, the sternum 
to be protruded forward, and the deformity known as pigeon-breast becomes often 
pronounced. Curvatures of the spinal column, especially kyphosis, are common, 
and distinct degrees of lateral curvature are frequently begun as a rachitic 
deformity, to be magnified by perverted muscle-action as the child grows older, 
[n the pelvis the innominate bones approach each other, causing the pelvic cavity 
to become contracted, or the sacral promontory projects too far, or in various other 
ways the normal pelvic diameters are so far compromised that rachitic deformities 
of the pelvis constitute the most common and most serious obstacles to normal labor 
in adult women, and are the most frequent cause of major obstetric operations. 

While the rachitic changes in the osseous system are the most distinctive and 
easily recognized, numerous other organs and tissues of the body are more or less 
seriously compromised. Ventricular dilatation, leading to chronic hydrocephalus, is 
one of the common results of rachitis of the skull, which may be followed by con- 
vulsions and may terminate fatally. So, again, we get porencephalon and cerebral 
sclerosis. Disturbances of digestion are common in rickety children : the liver is 
sometimes decreased, sometimes much enlarged; the spleen, particularly, often 



PLATE X. 










i 






Congenital Pseuclo-Raehitis, showing Aplasia of Cartilage ; 

a, Osteo-Periosteum ; b, Quiescent Cartilage; 

c, Periosteum penetrating between 

Bone and Cartilage. (Klebs.) 



SCURVY AND RICKETS. 191 

enlarges, and sometimes to enormous dimensions. In various other parts of the 
body we get the same expressions of malnutrition as are met with in tubercular 
disease. Rickety children perspire easily, particularly at night, when the head will 
often be found bathed in perspiration. They are fretful and irritable as a rule, and 
difficult to control. A child with protuberant belly, due to enlargement of liver 
and spleen, as well as to crowding up of pelvic organs, with relaxation of abdom- 
inal walls, with a contracted and distorted thorax, with the skull flattened on 
the top, with clubbed bone-ends, with a history of resting badly at night and 
sweating profusely, constitutes a clinical picture of rachitis so marked that it can 
be recognized at a glance. Between this picture in its worst forms and the 
slightest deviation from the ideal type one may meet with all degrees in manifesta- 
tions of rickets in the children of the rich or the poor, while in adults one may 
often see evidences of that which had obtained during early childhood. In order 
that all these features may be made out the children should be stripped and 
examined from head to foot. 

While rickets may be a very acute disease, it is, as a rule, chronic, 
and children dying essentially from this disease die rather from cerebral 
or other manifestations which may be regarded as in some degree acci- 
dental. Scurvy and other nutritive disturbances may be associated with 
rickets. 

Treatment. — The treatment for the condition consists mainly in 
proper nutrition. Mother's milk is certainly preferable to any other, 
and should be insisted upon if possible. If feeding must be artificial, 
it should be in accordance with the very best precepts of modern thera- 
peutics. Cod-liver-oil emulsions are of advantage ; compound syrup of 
the hypophosphites is a remedy of great virtue. Very minute doses of 
phosphorus seem to be of value — 1 milligramme pro die. It is a mis- 
take to let rickety children begin to walk, or even to creep, too early. 
They should be kept, so far as possible, in cribs or upon the back. 

The modern opotherapy of rickets includes as a most valuable 
adjunct the exhibition of thyroid and pituitary extracts, from which 
remarkable results are often seen. The dose must be graduated to the 
age of the patient, based on a dose of five grains for an adult, and 
given thrice daily. This will by no means preclude the necessity for 
most careful regulation of diet, etc., but will constitute a most valuable 
adjunct in treatment. ( Vide N. Y. Med. Jour., Dec. 12, 1896, p. 785.) 

The deformities due to rickets are so numerous as to constitute a 
large part of those to which special or orthopaedic surgery is addressed. 
The mechanical and operative treatment of these cases will be referred 
to in other and appropriate parts of this work. 



CHAPTER XIV. 

SURGICAL ASPECTS AND SEQUELAE OF OTHER INFECTIONS 

AND DISEASES. 

By Roswell Park, M. D. 



As the result perhaps of the conditions which, two centuries ago and 
more, so distinctly separated the barber-surgeons from the practitioners 
of medicine, there has been evolved, partly from tradition and partly 
from custom, an artificial and unfortunate separation of surgery from 
so-called internal medicine. The consequence has been a more or less 
deep-rooted feeling, in the minds of young practitioners especially, that 
medical cases were to be treated exclusively by non-operative measures, 
and that surgical cases could scarcely be expected to present any per- 
plexities that were not to be solved by an operating surgeon. It has 
been no small part of the benefit resulting from modern teachings that 
these imaginary boundaries and limitations have been swept away ; and 
one of the lessons which this text-book is intended to inculcate is that 
broad principles underlie disease conditions, and that one must appreci- 
ate their bearings thoroughly in order to practise either medicine or 
surgery successfully. In order better to inculcate this teaching I have 
deemed it wise to insert a chapter with the above general heading, 
in order to impress, so far as one may, the statement which some 
learn too late, that any of the co-called internal diseases may present 
at almost any time indications, sometimes urgent, for distinctly surgical 
interference. Some of the surgical sequelae of the exanthematous and 
continued fevers are well known and commonly recognized : for exam- 
ple, orchitis following mumps, suppurative inflammation of the middle ear 
after scarlatina, and bed-sores after typhus and typhoid. These are, of 
course, easily recognized, but concerning many others the text-books are 
singularly silent. 

Moreover, scarlatiniform eruptions occasionally follow various opera- 
tions and give rise to great perplexity. (Vide Med. News, Feb. 20, 
1897, p. 234.) 

Dysentery. 

Joint-complications in this disease have been recognized from the 
earliest times. One hundred and fifty years ago Strack expressed him- 
self thus : " If the dysenteric poison affect only the chest, it causes 
asthma ; if the limbs, it produces arthritis ; if both, abscess." Joint- 
pains and swellings, with other suppurations, have been noted in several 
of the epidemics of this disease which have ravaged various parts of the 
world at different times. Post-dysenteric arthritis may assume notice- 
able and even pyaemic aspects, and is occasionally fatal." The bones and 

192 



SUROIGAL SEQUELJE. 193 

joints may become involved in painful and even suppurative swellings, 
not alone during the active stage of the disease, but during the period 
of convalescence ; while mildness of the primary attack does not neces- 
sarily provide immunity from later complications. Here, too, as in 
many other instances, thrombosis of large veins or thrombo-phlebitis is 
also observed. When the joints are involved, it is usually in irregular 
order and not simultaneously. Joint-lesion does not necessarily proceed 
to suppuration, perhaps only to the point of oedema and fluid exudation 
or hydrops. 

Cholera. 

Cholera is usually too rapid and too violent in its course to be fol- 
lowed by secondary infections. Nevertheless, Poulet reports from Val- 
de-Grace several instances of articular and osseous lesions, some of 
these characterized by mere effusion of fluid which was sometimes very 
thick and resembled balsam, while at other times pus was present. 

Pneumonia. 

Pneumonia having now taken its place as a distinct germ-disease, 
and the micrococcus of Frankel and the capsule coccus of Friedliinder 
being now well established as the active agents in the two principal 
forms of this disease, we need not be surprised at finding collections of 
pus in various other parts of the body. For the most part, the surgical 
sequels of pneumonia occur as a post-pneumonic pyarthrosis, which in 
time past was also considered as a rheumatic affection. These lesions 
are probably of embolic or, strictly speaking, of metastatic origin. 

Influenza, or Grippe. 

Within the past few years this disease has assumed great prominence 
in medical literature, and not a few instances have been reported of 
surgical sequela? — abscesses, purulent ear disease, pyarthrosis, bone- 
lesions, etc. Even necrosis has been repeatedly observed. 

Measles and Scarlatina. 

The frequency with which these exanthems are followed by surgical 
complications has been noted by many authors. Inasmuch as the infec- 
tious agent is not yet recognized, we must probably consider their sur- 
gical sequelse as due to secondary pyogenic infections, which are relatively 
very common. 

Remembering what has already been said upon the principal ports of entry for 
disease-germs, in connection with the notable lesions of the mucous membranes 
and the lymphadenoid tissue of the nasopharynx which are characteristic of these 
two diseases, it will be readily appreciated how pyogenic organisms may secure an 
entrance permitting their distribution to various parts of the body, while the 
lowered resistance of these patients permits the pernicious activity of these germs 
to make itself felt when otherwise it would not be. It is notorious that surgical 
tuberculosis appears often as a sequel of the exanthemata, and it is in no degree 
straining after effect when one explains the entrance of these germs in the way above 
described. Consequently, in the lymphatics, in the periosteum, bones, and joint- 
cavities especiallv, and iii and about the eye and ear, we very frequently find mani- 
festations of suppurative disease. It is generally believed that these sequelse are 

13 



194 SURGICAL DISEASES. 

more likely to appear when the eruption has been incomplete. The fact that 
hyperplastic thickening of periosteum and neuralgic pains of the affected parts are 
often met with without suppuration has given, in time past, some reason for the 
rheumatic character which Bonnet and others have ascribed to these manifestations. 

While the absence of pus takes these out of the category of pyogenic 
infections, it nevertheless leaves them still as surgical complications 
which have often to be dealt with by mechanical measures, such as 
orthopaedic apparatus, etc. ; while too frequently more or less formidable 
operations, as for relief of ankylosis, etc., have to be performed. Post- 
scarlatinal arthralgia may be explained as a local ischsemia ; so may 
acute swelling or chronic thickening. But pus is always an expression 
of infection, and cannot be otherwise regarded. Retropharyngeal 
abscesses and a peculiar necrosis of the alveolar process of the jaws, 
particularly described by Salter, are among the various serious surgical 
complications of scarlatina. Epiphyseal separations and purulent 
destruction of ribs have also been noted. 

Typhoid. 

Although in elaborate treatises, as by Liebermeister and Murchison, 
bone- and joint-complications find no mention as sequels of typhoid, 
they have nevertheless long been recognized by surgeons. Post-typhoid 
hip-dislocations have been reported by several German surgeons. Boyer 
observed spontaneous dislocation of both thighs after what he called 
" essential fever," and the general topic of spontaneous luxations sub- 
sequent to typhoid has been seriously discussed by the German Congress 
of Surgeons. 

Those affections of joints which used to be considered rheumatic occur much 
less often after typhoid than after dysentery. Nevertheless, post-typhoidal arthral- 
gia and myodynia have been recognized by several French writers. Probably not 
a few times patients with affected joints, supposed to be rheumatic, have later 
been discovered to be suffering from genuine typhoid fever, and it has been after- 
ward recognized that the joint-lesion was merely a bizarre expression of the 
typhoid poisoning. The works on general practice call attention to the frequent 
complications of the pleural and pericardial serous membranes in this disease. 
They say little, however, about the implications of the articular serous membranes 
though one is as easy to explain as the other. Post-typhoidal polyarticular serous 
arthritis has been described by more than one writer. Multiple joint- abscesses 
have been more rarely seen. Pus has also been known to collect, not only in the 
joints, but in the tendon-sheaths and bursa?. The lymph-nodes are also frequently 
affected, and cervical, axillary, and inguinal abscesses are not rare. Post-typhoidal 
pyarthrosis, as leading to spontaneous luxation, has had even a medico-legal 
interest, since luxation has been known to occur while raising or lifting a patient 
the question of violence being subsequently brought into court. When the joint 
disease assumes the monoarticular form it is likely to terminate in suppuration • 
when polyarticular, pyarthrosis is much less common. In the pus from many 
of these abscesses typhoid bacilli may be recognized, but by no means in all. I 
have found them in a case of abscess in the abdominal wall occurring during con- 
valescence from typhoid in a young woman. A non-suppurative but extremely 
painful form of periostitis is occasionally met with ; and I never have seen more 
exquisite tenderness nor expressions of greater suffering than I met with in a case 
of this kind in a young lad in whom the bones of both lower extremities of the 
pelvis, and the lower spine were all involved. The slightest jar upon the floor 
called out a cry of pam, and to minister to his ordinary wants was a most distress- 
ing task. He eventually recovered without any pus-formation. Deep suppura- 
tions in bone are less often met with, but occasionally occur ; even necrosis with 
separation of sequestra has been noted. 



SURGICAL SEQUELS. 195 

Thrombosis and thrombo-phlebitis are also well-known sequels of 
typhoid, which may lead to most unpleasant complications. Typhoid 
fever appears to bear a peculiar relation to the growth of bones, since it 
has been noticed that during its course, or during convalescence, they 
show an extraordinarily rapid growth in length, even to the extent of 
1 mm. a day. This is probably caused by the irritation of the typhoid 
toxine upon the osteogenic tissue, since hypersemic areas have, by numer- 
ous observers, been found in the bone-marrow of those dying of the 
disease, and bone-pains are a frequent accompaniment of the disease. 
Typhoid bacilli have the power of remaining latent in the tissues for 
considerable lengths of time after cessation of all active symptoms, and 
they have been found alive and capable of active growth so long as 
seven months after cessation of the fever. Remembering the multiple 
ulcers of the lymphoid tissue which characterize the intestinal lesions of 
typhoid, one will not find it hard to explain pyogenic or other septic 
infection by absorption through these open ports of entry ; and the 
typhoid bacilli themselves, entering the circulation through these paths, 
may be carried to all parts of the body, and have been found in the pia 
— in fact, everywhere. 

Diphtheria. 

This also belongs to the diseases frequently complicated by lesions, 
aside from those of laryngeal obstruction, calling for surgical relief. 
Abscess occurs so frequently as to scarcely call for comment. Here, as 
in the cases of scarlatina, the location of the throat-lesions and the 
absorbing powers of the lymphadenoid tissue so completely involved 
will readily account for all septic or pyogenic manifestations at a dis- 
tance. Multiple abscesses have been found, for instance, in the liver, 
the spleen, and lungs, in and around the bones — everywhere, in fact, 
where abscesses can form — betokening thereby a pysemic manifestation. 
Infectious nephritis is also common. 

Mann, of Denver, has communicated to me personally, since the first 
edition of this work, cases of embolus of the femoral artery with result- 
ing gangrene, as sequels of diphtheria, as well as instances of true diph- 
theria of the penis, established by bacteriological diagnosis. 

Mumps. 

The infectious character of this disease is not questioned to-day, 
although not definitely established. Orchitis, ovaritis, stomatitis, 
enlargement of the tonsils and spleen, and albuminuria are frequent 
accompaniments of the disease, while articular and periarticular compli- 
cations have been noted by several writers. Bursal abscesses and pyar- 
throses have also been reported. In time past these surgical complica- 
tions have been spoken of as rheumatoid or rheumatic, their essential 
significance not being recognized until comparatively recently. 

Variola. 

The writers of the earlier part of this century allude frequently to 
the rheumatoid complications of smallpox, among which pyarthrosis 



196 SURGICAL DISEASES. 

seemed perhaps the most common, as certainly the most serious. The 
various arthropathies are the most interesting of the surgical complica- 
tions of this disease. That joints become swollen, red, and painful is 
not infrequently noted, and that one joint after another is involved is 
also the usual programme. 

Infectious Endocarditis. 

The individuality of this condition has been recognized only within 
the last thirty years, and accurately only within ten. That it deserves 
the characterization of " malignant " often given to it is well known. It 
is, in fact, an infectious disease with a special localization in the heart, 
the term cardiac typhus, given to it by some, being very expressive. 
Although so apparently spontaneous, it is itself, in fact, usually a sec- 
ondary lesion, perhaps sometimes a primary infection. When we con- 
sider the peculiar location of the disease, we shall have no difficulty in 
appreciating the readiness with which metastatic complications may 
arise. The arthritic manifestations, too, often assume a pysemic cha- 
racter, and even at the beginning of the affection, as Trousseau pointed 
out, there are frequently severe joint-pains. 

Dental Caries. 

Nearly one hundred species of micro-organisms from the mouth 
have been studied and identified by W. D. Miller, who has clearlv 
established that dental caries is due to the specific action of some of 
these parasites, which, gaining entrance into the dental tubules, deter- 
mine fermentation and acid-production, with erosion of the dental struc- 
ture of the teeth and an increase in softening and destruction. In this way 
the teeth, as already indicated in Chapter III., become wide-open paths 
of infection for germs which may travel but a short distance, causing 
only local disturbance, or which may be carried to other points about 
the head, producing disturbance in the antrum, in the neighboring bones, 
in the middle ear, and not infrequently in the brain. Abscess in the 
brain has been distinctly traced to caries of the teeth. Tubercular in- 
fection is also common through this channel, and its most common ex- 
pression is probably the invasion of the cervical lymphatics, superficial 
and deep, constituting those lymphatic tumors of the neck formerly 
known as scrofulous, with their disastrous train of adhesions, suppura- 
tion, erosion, etc. 

Syphilis and G-onorrhcea. 

These are surgical affections whose secondary complications in the 
way of abscesses, infarcts, tumors, etc. will be dealt with in other parts 
of this work. It will simply be well to group all of these infections— 
those just mentioned— along with anthrax, glanders, etc. into a class of 
infections which may be followed by tardy or verv late surgical sequela? 
which may call for more or less radical operation". In the case of gon- 
orrhoea this is seen best, perhaps, in the so-called pm-tubea of the female 
pelvis, which often call for operations years after the date of the pri- 
mary invasion. 



SURGICAL SEQUELS. 197 



The Puerperal State. 

This is seldom followed by surgical sequelae, save in the instance of 
mechanical lacerations demanding plastic repair, or of septic infections, 
which, when life is saved, sometimes lead to disastrous, though remote, 
consequences. Puerperal septicaemia is in no respect different, path- 
ologically speaking, from septicaemia due to any other presumably strep- 
tococcus invasion ; and the predilection which streptococci manifest for 
serous membranes, and especially joints, is well known. Consequently, 
after puerperal fever one may meet with articular or periarticular ab- 
scesses, affections of tendon-sheaths, lymphatics, etc., or the complica- 
tion may assume a different type, the veins and their contents being 
mainly involved, with thrombosis, infarct, etc. for its immediate results. 
The possible outcome of these various lesions will be appreciated if one 
simply reflect upon the known course of the blood and bear in mind the 
facts stated in Chapter II. 

As stated at the outset, it was intended to make this chapter sug- 
gestive rather than complete. In summarizing it would be well, there- 
fore, to say that there is probably no disease of known or suspected 
germ-origin which may not be followed by disastrous or unexpected 
surgical complications, while even those degenerative changes for which 
as yet no theory of parasitism has been invoked are followed by con- 
ditions, often painful in the extreme and crippling, which may call for 
most serious surgical measures. In other words, the surgical complica- 
tions of any so-called non-surgical disease may loom up at any moment 
in any case, and may even tax to the utmost the resources of a surgeon, who 
should be promptly summoned in the unwillingness of the general practi- 
tioner to act as such. Surgical sequelae are always unfortunate, but are 
always most so when unfortunate delay in their recognition or in sum- 
moning special help has been permitted to occur. 



CHAPTER XV. 

POISONING BY ANIMALS AND PLANTS. 

By Roswell Park, M. D. 



Certain poisons or deleterious substances are introduced in various 
ways into the human system from without, some of which produce only 
symptoms of moderate intensity, while others are quickly fatal. Thus, 
it is authentically stated that in India many thousands of individuals 
lose their lives every year as the result of the bites of poisonous snakes. 
Nothing approaching such injuries in frequency or intensity can be found 
in any other part of the world. Animal poisons may be introduced by 
animals of many species. The poison of hydrophobia has been already 
sufficiently described. The bites of the mammalia may be serious and 
may be followed by septic symptoms, but they are not regarded as due to 
any special toxine secreted by the animal. A number of reptiles, how- 
ever, possess special poison-glands which, for the most part, are con- 
nected with a tooth on either side of the upper jaw which is canal- 
iculated and serves as a duct through which the poison is injected when 
the animal inflicts its bite. 

The principal poisonous serpents in North America are the rattlesnakes — of 
which there are several species, usually placed at eighteen — the copperheads, the 
moccasins and the vipers. Some of these have movable poison-fangs, some fixed. 
In other parts of the world others equally or even more poisonous are known. 

The poison-gland is analogous to the parotid in location and structure. The 
duct which runs through it is so dilated as to contain a small amount of the pecu- 
liar poison. The amount of poison contained in these reservoirs varies from eight 
to twelve minims, and is secreted somewhat slowly. It seems to be, in some cases 
at least, a glucoside ; in others, a toxalbumen. It is capable of being preserved 
either dry or in alcohol or glycerin. The active poisonous principle seems to per- 
tain to a globulin, or to a peptone. Almost all of these venoms are innocuous if 
swallowed, and like septic infections seem inoculable only through the tissues and 
the circulating fluids. According to Mitchell, the venom of the rattlesnake 
renders the blood incoagulable, paralyzes the walls of the capillaries, and facili- 
tates escape of leucocytes into the tissues, thus making actual hemorrhagic swelling 
occur easily ; while the red corpuscles rapidly lose shape and fuse together into 
irregular masses and their hemoglobin is dissolved or disappears. This poison 
seems to paralyze both the respiratory centre and the heart. Cobra-poison, not 
containing globulin, at least to such extent, does not produce the rapid changes of 
rattlesnake poison. 

Symptoms. — A snake-bite is like a hypodermic injection of a deadly 
poison, and symptoms set in usually very promptly. These are both 
local and general. There is more or less local pain, with swelling and 
discoloration, these being due to effusion of blood. They increase in 
intensity, and are followed by vesication and necrosis of tissues — i. e. 
gangrene — if the patient survive long enough. Constitutional symp- 

198 



POISONING BY ANIMALS AND PLANTS. 199 

toms are not long delayed, and are characterized by severe prostration, 
including cold, clammy sweat, feeble and rapid pulse, irregular respira- 
tion, etc. When patients die, they die usually in collapse. The patho- 
logical changes are not sufficiently well marked or characteristic to 
detain us here. 

Treatment. — Treatment of snake-bite must be most prompt if it is 
to be successful. It should consist of the promptest possible incision 
and drainage of blood from the part, with application of a tight ligature 
or tourniquet above the bite, in order to prevent diffusion into the rest 
of the body by means of the returning blood and lymph. Bleeding 
should be facilitated by cups or by sucking of the wound. If there be 
any known antidote to snake-poison, it consists of potassium perman- 
ganate or calcium hypochlorite (chloride of lime), which may be applied 
locally in solutions, the former strong enough to have a very marked 
color and capable of producing local irritation (1 per cent.). Along 
with these local measures, constitutional stimulation should be most 
active by means of both volatile and other stimulants. There is a 
popular fallacy in favor of inducing alcoholic intoxication. To do 
this is undoubtedly a mistake. Nevertheless, alcohol may be given 
freely, dosage being limited not by amount, but by effect. Strychnia, 
digitalis, atropia, etc. will often prove serviceable. The tourniquet 
should be after two or three hours very gradually released, while one 
should be ready to antidote the poison which may thus enter the system 
with the necessary doses of stimulants above mentioned. Even so much 
strychnia as half a grain may be administered in divided doses with 
happy effect, it being apparently, in large measure, a true antidote to the 
snake-venom. There is much reason from recent experimentation to 
expect benefit from a serum-therapy — i. e. by injection of serum from 
immunized animals who have been fortified by increasing doses of the 
snake-poison. In this country such treatment, however, will be called 
for so seldom that there is not the hopeful outlook for the serum-therapy 
of snake-bite that there is in India. 

A large lizard found in the southwestern part of this country and in 
Northern Mexico, known as the Gila monster (Heloderma suspectum), 
is generally credited with being a poisonous animal. The probability 
is that the bite is fatal to some of the lower animals and may produce 
more or less serious disturbance in man. Nevertheless, there is little 
real evidence that this is to be considered in the same category with the 
venomous serpents above mentioned. 

Certain species of spiders are venomous, the tarantula being the 
best known. Certain scorpions also inflict poisonous stings, and centi- 
pedes and other animals occasion at least serious local disturbance by 
bites or stings. These insects and animals seldom attack unless irritated 
or disturbed. Tarantula-bites are occasionally inflicted in the Northern 
States by spiders which have concealed themselves in shipments of fruit, 
bunches of bananas being especially likely to be their hiding-places. 
The injuries inflicted by these animal organisms cause local pain, con- 
siderable swelling, with remote effects on the nervous system, prostra- 
tion, restlessness, etc. They are seldom fatal, but may cause exceeding 
great annoyance and even serious disturbance. These cases are to be 
treated in the same way as bites of poisonous serpents, adapting the 



200 SURGICAL DISEASES. 

measures and the energy of the treatment to the severity of the symp- 
toms. 

Wasps, hornets, and bees are capable of inflicting severe stings, 
while smaller and more domestic insects, like mosquitoes, bedbugs, etc., 
inflict minute injuries, which, nevertheless, sometimes occasion excessive 
annoyance. Their sting is followed by pain, burning sensation,_ some- 
times intense itching, and more or less swelling. Enough poison is 
deposited to produce local vasomotor paralysis, as the result of which 
wheals resembling those of urticaria, or more extensive swellings, quickly 
result. If the sting of an insect has been broken off in ridding one's 
self of it, it may remain and intensify the disturbance. Two or three 
injuries of this kind create at most local disturbance, but there are 
numerous instances on record where men and animals have been stung 
to death when attacked by swarms of these little enemies of our race, 
death apparently being due to intensification of effect owing to increased 
dosage of poison. If a sting occur upon loose tissues, like the eyelid, or 
upon the tongue or lips, swelling and suffering may be extreme. If 
symptoms of depression present, they must be combated by stimulants, 
diffusible or other, and by hypodermic medication pro re nata. Local 
discomfort may be alleviated by ice, by menthol, by chloral-camphor, etc. 1 

The arrow-poison of various Indian and savage tribes is a compo- 
sition of very variable and usually unknown nature. It is compounded, 
for the most part, from vegetable substances, and, if one may judge from 
the specimens of curare sold by importing houses, their strength must 
be most unreliable. 

While some of these preparations are made by the natives from species of 
Strychnos growing in the northern part of South America, this tree certainly is 
not in universal use for this purpose : in the East Indies they are made from a 
species of Upas (the deadly Upas of song and story). Some of the poisoned arrows 
of certain tribes are dipped in putrefying blood. A wound made by these is not 
necessarily promptly fatal, but would tend to kill by setting up septic disturbance. 
The vegetable poisons have, for the most part, the property of paralyzing the 
motor nerves and the circulation, to such an extent even that death may occur 
within a few moments after injury. All of these poisons are innocuous when 
swallowed, and game killed by their agency may be eaten with impunity. Arrow- 
poison of the vegetable variety which is not fatal within a few hours may be 
recovered from if only stimulation be vigorous enough. Artificial respiration is a 
factor of very great importance in keeping such patients alive. 

Many of the lower forms of marine animal* are capable of inflicting 
stings by their rays, or minute injuries in other ways, which give rise to 
great temporary annoyance. The stinging nettle, etc. are instances of 
this kind. The lesions produced in this way partake of the nature of 
a more or less acute dermatitis. 

In the vegetable kingdom there is one species of plant which is 
capable in certain instances of [producing the most intense dermatitis. 
I refer here to the so-called poison-ivy (Rhus toxicodendron, etc.). Not 
all individuals are susceptible to this poison — least so those of thick 
skin and dark hair. It is rather those of blond type and thin skin who 
seem most liable to its irritation. 

1 Oil of lavender is a pleasant means of local protection against mosquitoes, etc. Oil 
of tar is also in common use. A mixture of equal parts of camphor and chloral, with 
menthol dissolved in the mixture (camphor and chloral when mixed without other 
ingredients quickly form a dense fluid like glycerin), gives great local relief from the 
itching and pain of insect -bites. 



POISONING BY ANIMALS AND PLANTS. 201 

The active agent is toxicodendric acid, and it is capable of setting up the most 
intense irritation of the eczematous type, with a large amount of hyperemia and 
oedema, especially of soft tissues. Thus, when the face is involved the eyelids 
become so puffed as to make it almost impossible to separate them for purposes 
of vision. Ivy-poisoning comes practically always from contact with the plant, 
which grows in various parts of the country, and with which one may come 
in contact in most unexpected places. Symptoms supervene usually within 
twenty-four hours, probably much less, and in well-marked cases do not subside 
for three or four days. The itching is almost intolerable, and is best combated by 
strong alkaline solutions or brine. A very dilute bromine solution is also of very 
great benefit, but is not always ready at hand in instances of ivy-poisoning in the 
woods. Salt and soda, however, are nearly always at hand, and can be used with 
great relief in pretty strong solutions. Vigorous catharsis will also help, and 
hypodermic injections may be necessary for the enjoyment of sleep. 

Certain other species of sumach will also produce similar symptoms, usually- 
less severe, in a comparatively small proportion of susceptible individuals. This 
is true in milder degree of certain species of the genus Cypripedium. 



CHAPTER XVI. 

ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 

By Roswell Park, M. D. 



Delirium tremens as an expression of acute or subacute alcoholic 
poisoning is in no essential degree a surgical condition. Nevertheless, 
it so notably and often so disastrously complicates surgical cases that it 
is necessary to take it into account in this place. This form of toxic 
delirium may occur while the individual is still drinking hard, or not 
until several days have elapsed after active drinking has ceased. It is 
precipitated in many cases, where otherwise it would simply remain 
imminent, by surgical injuries and operations. In an individual in whom 
it is feared, we should become apprehensive in proportion as the muscu- 
lar system becomes unsteady and tremulous, the mind disturbed, and 
the individual sleepless. 

Patients in a well-marked condition of delirium tremens become 
often so uncontrollable and so lost to sensation of pain that it raav be 
practically impossible to enforce the physiological rest which their sur- 
gical condition demands. The restraining sheet will answer for general 
purposes, but the strait-jacket, and even the most carefully applied 
plaster splint or mechanical restraint, will not always be sufficient to 
carry out the indication. Ingenuity may be taxed beyond its limit to 
enforce the needed rest, for patients will tear off bandages and injure 
themselves in various ways. 

Treatment. — The local indications,, as just expressed, are in the 
direction of physiological rest if it can possibly be enforced. Constitu- 
tionally, the indications are in two directions : First, to keep up nutrition 
and excretion; secondly, to properly medicate. Nutrition is difficult 
unless excretion be maintained. Hot-air baths, laxative enemata, pref- 
erably of cold water, when necessary, and administration of a fluid and 
easily assimilable diet are measures of the utmost importance. Should 
the case present features of an acute alcoholic gastritis, stomach-feeding 
may be altogether abandoned and the rectum utilized for this purpose. 
Medication must consist mostly of stimulants, with such sedatives, laxa- 
tives, diuretics, etc. as may be necessary. Whatever may be the general 
wisdom of the course, it is probable that in surgical cases it is not wise 
to abruptly deprive these patients of the alcohol which they have so 
abused. Consequently, it is well in many instances to continue a mild 
degree of alcoholic stimulation, at least for a time, letting them down, 
as it were, by the easiest possible stages. Two stimulants rank higher 
than all others put together as substitutes for alcohol, and in some 
degree antidotes to its effect. These are strychnia and digitalis. The 
former should be given preferably subcutaneously ; the latter by the 

202 



ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 203 

stomach if tolerated ; otherwise, by the rectum or beneath the skin. 
My own preference for the use of digitalis is in the direction of large 
and few doses. I have not hesitated in many instances to give 1 5 c.c. 
of ordinary tincture, repeated once or twice at intervals of a few hours, 
and then to discontinue it. The effect is both to brace up the heart and 
to equalize the circulation, while at the same time it acts as a most 
efficient diuretic ; and I never have had occasion to regret such doses ; 
on the other hand, I have often seen them do great good. 

Of the sedatives, bromides, chloral, and remedies of that class are those most 
often resorted to, and must be given in doses sufficient to meet the indication. One 
should remember, however, that they are all more or less depressant, and that 
stimulation by strychnia, etc. is necessary even while they are being administered, 
in spite of the apparent physiological antagonism between them. Occasionally 
nothing will take the place of opium, best given in the shape of morphia intro- 
duced beneath the skin. Whatever may be one's tastes or preferences for drugs 
under ordinary circumstances, he can but feel that in serious surgical cases com- 
plicated by delirium tremens the first indication is toward the surgical lesion, and 
preferences, past methods, etc. must all be secondary to enforcing such quietude 
as shall permit repair of injury. The first indication, then, in most of these 
instances is in the direction of ensuring rest and sleep, even at the expense of 
inconvenience or misfortune in other directions. I write this with a full realizing 
sense of its significance, yet with positive conviction as to its truth. 

Traumatic or Post-operative Mania. 

This it would be difficult to distinguish from a form of mania uni- 
versally recognized and known as puerperal mania, the two conditions 
being, I take it, essentially similar. Regarding these cases from a 
surgeon's standpoint, and carefully avoiding any attempt at minute 
explanation of the phenomena, I would only say that such cases are 
met with in the practice of operating surgeons, as in the experience of 
obstetricians, presenting themselves either as mild forms of harmless 
mental aberration, or assuming almost any of the types of insanity as 
made out and classified by experts in that subject. From the mildest 
mental alienation, then, up to furious and even homicidal or suicidal 
mania, one may meet with all degrees of departure from the normal 
standard. 

Toxic Antiseptics. 

As stated above, it is generally recognized that in people perhaps of 
peculiar idiosyncrasies the administration of certain drugs ordinarily 
considered harmless is followed by more or less toxic symptoms. 
Obviously, if this were universally the case, or even in the majority of 
instances, the use of these drugs would speedily be abandoned. As it 
is, it is well to at least have in mind the consequences which are 
occasionally known to ensue, and perhaps to weigh in every case the 
chances as to whether it be worth while to use a given substance of 
known occasional toxic power as against another which is not known to 
possess it. 

Of the less active antiseptic agents, there is, for example, boric acid, 
ordinarily considered absolutely innocuous, yet which is known rarely 
to cause intestinal disturbance, while in at least one instance serious 
toxic effects followed its use. Naphthalin also, ordinarily considered 



204 SURGICAL DISEASES. 

as harmless, will sometimes produce vertigo or vasomotor symptoms, 
especially when administered internally. So many of the antiseptic 
materials used are more or less irritating to the skin that such local ex- 
pressions as eczema, etc. provoke very little comment except on the part 
of the patients, whose comfort is sometimes temporarily very much dis- 
turbed by their action. Yet, inasmuch as it is the patients' welfare which 
we ordinarily seek, we must remember that the drug-eczema produced 
by corrosive sublimate, much more rarely by other antiseptics, which 
may so disturb a patient as to prevent sleep and make him irritable 
and particularly restless, is undoing very much of the good which we 
have sought to do him, because it is interfering with one of the first 
essentials of ideal wound-healing — ■/. e, physiological rest. 

Iodine, by itself or in certain combinations, is a drug whose activity 
should never be forgotten. Applied upon the surface, it ordinarily tans 
the skin, and, aside from being objectionable, does no good. Injected 
in solutions of varying strength, as it has been in times past more than 
at present, into serous cavities (for example, hydroceles, etc.), it 
occasionally gives rise to symptoms which may even be alarming. 
Fatal poisoning following its injection into an ovarian cyst has been 
reported, and I have seen alarming symptoms produced by injection of 
the ordinary solution into a hydrocele sac. Much of the virtue or- 
dinarily ascribed to iodoform is supposititiously credited to the libera- 
tion of free iodine by its decomposition. Whether or not this be true, 
it is certain that iodoform is one of the most frequently toxic of the 
antiseptic agents in ordinary use. In mild cases it produces headache, 
restlessness, wakefulness, and often a distinct taste of iodoform in the 
mouth. In more pronounced degrees of poisoning there is fever, with 
often mental derangement which may amount to delirium or even to 
acute mania, and may cause well-founded suspicion of meningitis. 
Death has repeatedly occurred, from syncope or in coma, after its use. 

Carbolic acid produces unpleasant effects, both upon patient and 
operator, or with whomsoever it may come in contact. Aside from 
its local effect upon the skin, which is most unpleasant, but which 
usually passes away within a few hours, it seems to affect especially the 
kidneys, causing often temporary albuminuria with discolored urine, 
deranged secretion, and sometimes much more acute forms of disturb- 
ance, similar to those met with after its internal use. Carbolic poison- 
ing was met with most frequently during the era when Lister's original 
directions were scrupulously followed, and at a time before Aye learned 
that it is much better to remove dirt than to try to antagonize its action. 
Certain eminent operating surgeons -were even compelled to discontinue 
its use because of its unpleasant effect upon themselves as well as upon 
their patients., 

Finally, among the powerful antiseptic agents in common use, the 
very active are the soluble preparations of mercury, ordinarily corro- 
sive sublimate, in solutions of varying strength, which are used for 
irrigation, douching, etc. and for preparation of dressings. Aside from 
an intense and even serious eczema which may follow its local use, one- 
may meet with any or all of the expressions of mercurial poisoning 
after using it, particularly on certain individuals of peculiar suscepti- 
bility to this drug. Salivation, intestinal irritation, and all other well- 



ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS. 205 

known phenomena of mercurial poisoning have been occasionally pro- 
duced, with the result that the solutions and preparations of corrosive 
sublimate now used are much weaker than those which were used at 
first, and that in many instances where it is desired to avail one's self 
of its properties we at the same time protect the area involved against 
toxic activities by dusting with some standard sterilized powder or by 
anointing it with some sterilized ointment which shall protect the skin, 
while at the same time permitting the dressings to be applied where 
they may best absorb wound-discharges. 



PART III. 

SURGICAL PRINCIPLES AND METHODS AND 
MINOR PROCEDURES. 



CHAPTER XVII. 

CONTROL OF HEMORRHAGE; ABSTRACTION OF BLOOD; 
PARACENTESIS ; COUNTER-IRRITATION. 

By John Parjienter, M. D. 



Control of Hemorrhage. 

The methods of controlling' hemorrhage are many, and vary 
according to the nature of the hemorrhage, the situation of the vessels 
concerned, etc. The subject will be considered in a general sense only 
in this place. We may divide our measures for the control of hem- 
orrhage into Temporary and Permanent, 

I. Temporary Measures. — Among the recognized temporary expe- 
dients are (a) Digital compression, which implies the use of the finger or 
thumb applied over the bleeding point or over the vessel at some acces- 
sible place in its continuity. The amount of force required for all 
vessels, provided they are situated superficially, is surprisingly little. 
(More force is required for arteries than veins, of course, and also 
where a large muscle-covering exists without underlying bone against 
which to press the vessel.) When the vessels lie deeply, however, this 
method is too tiring and inexact to be depended upon. Furthermore, 
long-continued pressure may endanger the vitality of the adjacent tis- 
sues. This danger and that of the conversion of an open into a con- 
cealed hemorrhage constitute two sequelae resulting from injudicious 
pressure which should always be avoided. 

(6) Haemostatic Forceps. — These serve a double use — to crush the 
vessel (in case of arteries) and to differentiate it from the adjacent tis- 
sues prior to torsion or the application of a ligature. It has bluntly 
serrated ends which easily catch and crush the vessel. Forceps are of 
various forms and sizes. For small arteries forceps usually effect per- 
manent closure after a few minutes' application. Even the largest 
vessels may be closed if the pressure continues sufficiently long. In 
using haemostatic forceps great care should be employed not to include 
any tissue excepting the vessel itself. Local necrosis is often caused by 
their too prolonged application to too much tissue, and doubtless fre- 
quently leads indirectly, if not directly, to suppuration in otherwise 
aseptic wounds. In removing the forceps it should not be made to 

207 



208 



SURGICAL PROCEDURES. 




tpart and tightly twisted with any kind 
of stick (cane, umbrella, etc.). As a 
~~ means of controlling hemorrhage tour- 
niquets possess certain elements of dan- 
If applied too long, at injudicious 



Illustrating forced flexion for control of 
hemorrhage. 



drag upon the vessel, and should be slowly removed in order not to dis- 
turb the clot already formed. 

(c) Tourniquets. — Of these the commonest, cheapest, and most gen- 
erally useful is the Esmarch tourniquet, which is a piece of f-inch 

rubber tubing about 1J to 2 feet long, 
with a hook at each end. A sim- 
ple rubber bandage does equally well. 
r Where neither is obtainable a hand- 

I places, such results as paralysis of im- 
■ ! portant nerves, sloughing, great oozing 
, of serum from the wound, and much 
after-pain may result. They are there- 
fore to be used with caution, and dis- 
pensed with as soon as the vessel can 
be isolated and closed. 

(d) Forced Flexion. — In suitable 
cases pressure can be made by putting 
a joint, such as the knee or elbow, in 
a position of forced flexion with immobilization, as shown in Fig. 43. 

II. Permanent Measures. — (a) Ligation. — This is done by tying the 
vessel with some form of ligature (catgut, silk, kangaroo-tendon, etc.). 
The ligature may be applied at the open end of a vessel or in its con- 
tinuity. Applied with moderate force, the middle and inner coats are 
cut through and curl up, although this is not necessary for the oblitera- 
tion of the vessel. 

The only object in using force sufficient to destroy the inner coats is to ensure 
so firm a hold upon the vessel as to prevent its slipping off. An internal clot 
forms, which reaches usually to the next highest branch, organization begins, and 
the ligated parts become a mass of cicatricial tissue. All in all, ligation is the 
simplest, safest, and best method of controlling hemorrhage. Some substitutes for 
ligation may be mentioned here : they are torsion and deep suturing. 

Torsion is effected in two ways : In small vessels it suffices to catch the end with 
a hsemostatic forceps and twist it around several times, stopping short of severing 
the twisted from the main portion. When dealing with larger vessels it is better 
to seize them near the end (one-third of an inch), with one haemostatic forceps 
applied at right angles to the axis, and, having secured this firmly, to then twist 
the distal portion as above described (four or five complete turns usually suffice). 
This method is applicable to vessels as large as the femoral, and has the advantage 
of enabling us to dispense with ligatures. The method is peculiarily valuable in 
plastic surgery and where scar is to be avoided. 

Beep suturing (ligature en masse) consists in passing a ligature through the 
tissues around a vessel by means of a needle whose points of entrance and emerg- 
ence are near to each other. The method is indicated in cases where the end of 
the vessel cannot be caught up, as occurs in certain wounds or in dense, unyielding 
tissues. 

(6) Pressure. — This may be effected by long-continued digital pres- 
sure or by leaving a hsemostatic forceps clamped upon the vessel for a 



CONTROL OF HEMORRHAGE, ETC. 



209 



period of from twelve to forty-eight hours according to its size and tone, 
and by the use of gauze or other form of dressing. It is most applicable 
in regions where other means for arresting hemorrhage cannot readily be 
employed ; that is, in the rectum, vagina, nose, medullary canal, socket 
of a tooth, wounds of the deep palmar or plantar arch, etc. The coap- 
tation of the edges of a wound by sutures is another method of apply- 
ing pressure, and is especially useful where the skin is vascular, as in 
the scalp and scrotum. 

Fig. 44. 




Obliteration of artery following ligation. 



(c) Styptics. — These are chemical agents which arrest hemorrhage by 
inducing coagulation of the blood. Chief among these are persulphate 
and perchloride of iron, powdered alum, tannin, gallic acid, nitrate of 
silver, vinegar, cocaine, chloroform and water (one drachm to the pint), 
turpentine, antipyrine (5 to 20 per cent, solution), Park's mixture of 
antipyrine and tannin, solutions of each, of 15 per cent, strength, 
mixed. If too strong, styptics easily cause necrosis and sloughing of 
the tissues, and thus prevent primary union. 

(d) Heat. — This may be applied in the form of water at the tem- 
perature of 120° to 150° F. or by means of the actual cautery. Hot- 
water irrigation is of great value upon extensive raw surfaces or in 
cavities which ooze. The actual cautery, of which the Paquelin is the 
best and most commonly employed, should be used at a dull-red heat 
and applied for a few moments to the bleeding point. It is a powerful 
haemostatic. It checks hemorrhage, either by forming an aseptic eschar 
at the end of the vessel or causing the end to curl up and invert, thus 
finally closing the vessel. A bright-red or white heat is not haemostatic 
in action. An iron heated to dull red or the galvano-cautery may be 
used in place of the Paquelin. 

(e) Cold. — In the form of exposure to air, ice-water, or ice cold has 
long been used for checking hemorrhage. It causes contraction of the 
muscular coat, and therefore acts more promptly and effectually in 
arterial than in venous bleeding. The exposure of an amputation-stump 

14 



210 SURGICAL PROCEDURES. 

to air set in motion by a fan quickly causes the surface to become dry 
and glazed over. 

(J) Elevation.— -If the upper or lower limb be held in a vertical posi- 
tion for sixty to ninety seconds and a tourniquet applied, we find that 
we have rendered the 'part almost bloodless; so also when hemorrhage 
is occurring elevation quickly lessens or stops the oozing from veins and 
capillaries. This is so well recognized that elevation of an amputated 
stump for the first few hours after operation is almost a routine practice. 

(g) Acupressure, acufilopresxure, and acutorsion are now rarely 
employed. Occasionally the one or the other method may be useful. 
Acupressure consists in passing a long needle through the soft parts in 
such a manner as to compress the vessel beneath it. When, in addition, 
we bind a ligature about the projecting ends of the needle, the procedure 
is called acufilopressure. Acutorsion consists in drawing out and trans- 
fixing with a needle the end of the vessel. The needle is then given a 
half or complete turn, when clot-formation occurs and hemorrhage is 
checked. 

Abstraction of Blood. 

(1) Venesection, or Phlebotomy. — This consists in opening a vein, 
preferably the median basilic, although the median cephalic may be 
selected, and, where cerebral inflammation or apoplexy exists, the 
external jugular is often chosen. It should be borne in mind that the 
median basilic vein crosses the brachial artery, being separated from it 
at this point by the thin aponeurosis of the biceps. In fat persons, 
where an excessive amount of fat covers the veins, venesection may be 
difficult. A bright light or reflector may be advantageously employed 
in such cases, the veins revealing their situation by their shadow. The 
opening into the vein should be made either above or below this point, 
the artery having been first identified by its pulsations. 

Venesection is usually done as follows : The elbow having been previously 
rendered aseptic, a bandage is applied about the middle of the humerus sufficiently 
tight to retard the venous return, but to leave the radial pulse quite perceptible. 
The arm is allowed to hang down and the fingers given some object like a roller 
bandage to grasp, to better fill the vein. In a few seconds the vein becomes quite 
prominent, when an oblique incision maybe made through the skin and wall of the 
vein, or, what is better, a bistoury may be thrust under the vein and a cut made 
outward. The opening in the skin should be generous to avoid subsequent infil- 
tration. The blood should be allowed to flow until the pulse becomes soft and 
slow. The amount necessary to produce this effect varies with the individual, but 
in general it averages between eight and twenty ounces. Should the flow become 
too slow before the desired effect has been produced, it may be hastened by having 
the patient alternately close and open his hand and tightly squeezing whatever 
object he may be holding. The muscular contraction induced increases the flow. 
When sufficient blood has been abstracted, the encircling bandage should be 
removed and antiseptic dressings applied with moderate pressure. The antiseptic 
management of venesection is highly important, as bent-arm, due to suppurative 
cellulitis and suppurative thrombosis, followed by fatal pvsemia, has occurred not 
infrequently. 

(2) Arteriotomy. — This procedure may be used where rapidity is 
necessary. The temporal artery is usually chosen because of its super- 
ficial situation, convenient size 1 , and the ease with which the bleeding 
from it can be controlled by pressure. Its exact position mar be deter- 
mined by its pulsation, which can be readily felt, and in "some indi- 



CONTROL OF HEMORRHAGE, ETC. 211 

viduals seen. The artery should not be entirely cut through to secure 
the best flow, although complete division is sufficiently effective. If 
only partial section of the artery has been made, when the bleeding has 
been completed the vessel should be cut entirely through and firm anti- 
septic dressings applied. 

(3) Scarification. — This is performed by making several small cuts or 
punctures in the affected part, through which the blood will exude more 
or less vigorously according to circumstances. Where applicable, heat to 
the part and the dependent position will promote exudation of blood. 

(4) Cupping. — This may be either dry or wet. In dry cupping the 
blood is simply drawn to the surface, and thus, in the strict sense of the 
word, is not abstracted. It is, however, taken from the congested part, 
its effect upon which is virtually the same as though the blood was 
removed from the body. 

Dry cupping is effected by using a cupping-glass or tumbler, the interior of 
which has been previously heated with an alcohol lamp or a piece of burning 
paper, or, better still, by rinsing one or two teaspoonfuls of alcohol around the 
sides of a glass, which is then inverted to allow the excess of alcohol to escape: 
the edges of the glass are wiped free of alcohol and the remaining film within the 
glass ignited. The glass is then applied to the affected area. The skin becomes 
congested and rises in the glass. By far the best, most rapid, and accurate cupping 
apparatus is the Allen surgical pump. 

Wet cupping implies the abstraction of blood from the body. 
Formerly it was done with a complicated instrument containing ten or 
twelve sharp knives working in a half-circle through slits in a metal 
plate fixed to a frame. The instrument is rarely or never used to-day. 
The complicated mechanism made it difficult to render it aseptic and to 
keep in order. A better way is to scarify the part with a tenotome or 
bistoury and apply the cupping-glass as before described. The amount 
of blood withdrawn will depend upon the degree of suction and the 
depth of the cuts. The cupping ended, an antiseptic dressing should be 
applied. 

(5) Leeches. — These are not often used at the present time. There 
are two varieties, the American, which can abstract about a teaspoonful 
of blood, and the tiwedish, which draws about three or four teaspoonfuls. 
The latter is most commonly used. 

Leeches may be applied as follows : The skin of the region selected is washed 
and, if necessary, shaved ; it is then smeared with milk or blood. The leeches are 
taken from their receptacle and allowed to swim in a basin of fresh water for two 
or three minutes, after which they are urged to crawl over a clean towel for a 
similar period. Each leech is then taken up in a test-tube or small glass, and this 
is inverted over the spot chosen, when the leech usually fastens upon the skin. 
Sometimes considerable time elapses before it will attach itself. When it has 
drawn sufficient blood a little salt or snuff will make it relax or drop off. The 
wound may then be dressed with some antiseptic gauze. 

Care must be exercised in the application of leeches. They should 
never be applied over loose cellular tissue, such as the scrotum, penis, 
or eyelid, nor over superficial veins, arteries, or nerves. When applied 
to the neighborhood or interior of cavities they should be prevented 
from going too far, either by stuffing the continuation of the cavity with 
cotton or gauze or by securing the leech. 



212 SURGICAL PROCEDURES. 

The mechanical leech is a device consisting of a scarificator-cup and exhausting 
syringe. After scarifying the part the cup is applied, a vacuum produced, and the 
blood slowly withdrawn. It is in no way comparable to the Allen pump, which 
possesses other advantages as well. 

Paracentesis. 

Paracentesis may be performed in one of three ways — viz. aspira- 
tion, tapping, or incision. 

Aspiration is the withdrawal of fluid from a closed cavity without 
the admission of air by means of an instrument with which a vacuum is 
produced and an outward flow of the fluid induced. There are many 
kinds of aspirator, from the piston trocar to the more elaborate bottle- 
aspirator of Potain, which is the one most commonly used. It consists 
of a suction-pump connected with a bottle by rubber tubing and pro- 
vided with stopcocks ; the bottle is, in turn, connected in a similar way 
with the needle. 

The bottle is first exhausted of air, when the needle is inserted into the cavity 
containing the fluid, the stopcock is turned, and the fluid flows into the bottle. 
Should this become full, the stopcock is turned off, the bottle emptied, and the 
process repeated until the desired amount of fluid has been withdrawn. The area 
about the point to be aspirated should be thoroughly aseptic, as should the instru- 
ment in all its parts, especially the needle or trocar. 

The place of puncture may be made anaesthetic with ice, rhigolene 
spray, or, what is usually more convenient, by touching it with a drop 
of carbolic acid, which is both antiseptic and anaesthetic. Aspiration is 
more commonly employed to remove effusions within the pleural, peri- 
cardial, ventricular, and subarachnoidian cavities, encysted collections 
within the abdomen, and fluid in the joints, especially the knee. 

Tapping is effected by means of the trocar and cannula. The same 
preparation of the instrument and parts should be made as in aspira- 
tion. The instrument should be plunged quickly and firmly into the 
cavity and the trocar withdrawn. If the trocar be a large one, it is 
better first to incise the skin with a scalpel to prevent the opening in 
the skin from remaining patulous. Where a large collection is to be 
removed it is well to attach a piece of rubber tubing to the cannula to 
carry the fluid into some receptacle, and thus avoid wetting the patient's 
clothing and immediate surroundings. Tapping is usually practised in 
dropsy, and when neither an aspirator nor trocar can be obtained the 
valvular incision may be employed. The skin having been drawn well 
aside from the line selected, an incision is made down through the skin 
and underlying tissues until the cavity is reached, and when drained 
sufficiently the skin is allowed to slip back to its original position. This 
puts the incision through the skin well to the side of that through the 
tissues beneath, and gives to the whole the action of a valve. The 
method has been successfully used in pleural and joint effusions, in spina 
bifida, and in cold abscesses. 

Counter-irritation. 

Like abstraction of blood, counter-irritation, except in the milder and 
less effective forms, has dropped out of fashion. So pronounced is the 
writer's conviction upon the value of this procedure as accomplished by 



CONTROL OF HEMORRHAGE, ETC. 213 

the actual cautery that he regards the Paquelin thermo-cautery as an 
almost indispensable part of a surgeon's armamentarium. Counter- 
irritation is of especial value in the treatment of chronic inflammation 
(so called) the result of chronic congestion and tissue new formation, 
in which condition it both relieves pain and promotes the absorption of 
existing exudates. 

The»various means of producing counter-irritation include rubefa- 
cients, vesicants, the seton, and the actual cautery. To these may be 
added issues and acupuncture, which, however, are rarely ever used at 
the present time. 

(1) Rubefacients. — In this list are found hot water, turpentine, mus- 
tard, ammonia, capsicum, chloroform, and others, most of which, if 
applied sufficiently long, produce a vesicant action. Speaking broadly, 
the effect of rubefacients is not of signal value in most surgical conditions 
requiring counter-irritation, and, inasmuch as their method of applica- 
tion is so generally understood, we may pass them by without further 
consideration. 

(2) Vesicants cause an effusion of serum and lymph under the skin. 
Chief among these are mustard, cantharides, chloroform, and ammonia. 

Mustard is usually employed as a plaster made by mixing equal parts of the 
flour with wheat or flaxseed meal, to which enough lukewarm water has been 
added to make a paste. (It should be remembered that boiling water, by altering 
the active principle, renders mustard valueless as a vesicant.) It may also be con- 
veniently used in the form of the mustard leaf, which is first dipped in warm 
water and applied. In either form the plaster should be left in situ for half an 
hour or more, and applied directly to the skin without intervening gauze or oint- 
ment, as is done where the rubefacient effect alone is desired. Although always 
at hand, and therefore convenient, mustard is not to be commended as a vesicant, 
because it is more painful than others to be mentioned and the resulting ulcers 
are often very slow in healing. 

Cantharis is used in two forms — the cerate and cantharidal collodion. 
The cerate may be spread upon adhesive plaster, leaving a margin suf- 
ficient for adhesion to the skin in order that the cerate may be held in 
place. It should be removed in from six to ten hours and followed by 
a poultice. Cantharidal collodion is an admirable form in which to use 
this drug, its advantages being that it is not easily displaced and can be 
applied to irregular surfaces. It is painted on the selected surface with 
a brush, several layers being applied. Chloroform and ammonia are 
both used in a similar way. A few drops are applied upon the skin and 
covered with a watch-cover, or absorbent cotton saturated with them 
may be applied and covered with oiled silk, greased brown paper, or 
some impervious material. Within half an hour vesication has been 
usually produced. The use of these agents is open to the same objec- 
tions as in the case of mustard — viz. pain and slow-healing ulcers. 
Silver nitrate, in strong solution, or the solid stick applied to the skin, 
produces vesication. 

(3) The Seton. — This consists of a subcutaneous sinus with two open- 
ings, through which some foreign body, usually silk, is passed. 

This is easily made by thrusting a needle having a generous eye and armed 
with large silk through the desired place, the ends of the silk being tied together. 
After two or three days the wound is dressed and the silk drawn back and forth 
through the wound a few times, this being subsequently repeated daily. The irri- 



214 SURGICAL PROCEDURES. 

tant effect may be increased bv smearing savin or mercurial ointment upon the silk. 
The writer has employed the seton in post-cervical pain with marked benefit. 

(4) The Actual Cautery.— In point of view of wide range of appli- 
cability, efficiency, and speedy action the actual cautery ranks first among 
counter-irritants. The old 'cautery-irons, the red- or white-hot poker, 
and other crude forms have been superseded by the Paquelin thermo- 
cautery. 

Its principle depends upon the power of benzine to render heated spongy plat- 
inum incandescent. Having heated the tip in an alcohol flame, the rubber bulb 
connected with the benzine receiver is compressed and the benzine vapor is forced 
into the spongy platinum, which becomes heated to any degree up to white heat, 
according to the pressure upon the bulb. 

When ready for use the following precautions should be observed : 
The part to be cauterized should be thoroughly cleansed and shaved. 
The cautery, having been brought to a white heat, should be touched 
upon the part in spots half an inch distant from each other, or in the 
form of streaks parallel or crossing each other. The amount of pressure 
and the duration of contact upon the skin will determine the depth of 
the burn, which it is better to limit to partial rather than to entire 
destruction of the cuticle. 

The counter-irritant effect in the former condition is greater because 
of the exposure of the terminations of the sensory nerves. After cau- 
terization has been produced the part may be dressed with ice-water, 
poultices, with or without some anodyne or an ointment containing 10 per 
cent, of iodoform. Where it is desired to keep up the effect the ulcer 
may be dressed with savin or mercurial ointment, as previously men- 
tioned when speaking of blisters. It is proper to mention here that the 
therm o-cautery may be used to produce a rubefacient effect. This is 
done by heating the largest tip to a white heat and holding it within a 
quarter or half an inch of the surface until the pain causes the patient 
to exclaim or the skin is seen to redden, when it should slowly be shifted 
an inch or so. The writer has found this of great sedative value in 
tympany following laparotomy, after synovitis, and other analogous 
conditions. 

Ignipimcture — /. e. puncture with a fine cautery-point, made by plung- 
ing it into the skin and underlying tissues in a number of places — 
produces admirable counter-irritation in deep-seated congestions or 
inflammations. 



CHAPTER XVIII. 

MINOR SURGERY AND BANDAGING. 
By John Parmenter, M. D. 



Knots. 

The knots in common use by the surgeon include the reef or square 
knot, the surgeon's knot, the granny, the Staffordshire knot, and the 
clove hitch. 

(a) The reef knot is formed by passing one end of the ligature over and around 
the other, drawing the single knot thus formed sufficiently tight, when the process 
is repeated, using the same end that was first employed. 

(b) The surgeon's knot differs from the reef knot only in the first stage of its 
formation, where the one end is carried over and around the other twice. This 
makes the knot more secure by preventing the slipping of the single knot while 
the second is being made — an accident which easily occurs where great tension is 



Fig. 4 




Fig. 46. 




Reef knot. 
Fig. 47. Fig. 48. 



Granny knot. 




Fig. 49. 




Clove hitch. 



Staffordshire knot. 



necessary or slippery ligature materials are used. The surgeon's knot requires 
more force to produce the same amount of tension. 



215 



216 



SURGICAL PROCEDURES. 



(c) The granny differs from the reef knot in that in the second stage of its 
formation the end first employed is passed under and around its fellow. It is a 
good knot, easily made and thoroughly secure, some authorities notwithstanding. 

(rf) The Staffordshire knot is especially useful for securing pedicles. It is made 
by transfixing the pedicle with a double-threaded transfixing needle, slipping the 
loop over the stump, and pushing it down to the point of entrance of the ligatures 
(the needle having been withdrawn), when one ligature is placed over and the 
other remains under the loop : each is pulled tightly and secured by a square knot. 
The Staffordshire knot thus secures each half of the pedicle, and is a safe and 
reliable knot when properly made. When carelessly made it is highly dangerous. 

(e) The clove hitch may be properly considered in this place, although not em- 
ployed in the class of cases in which the knots just described are used. It is 
easy to make and does not slip. In fact, the more it is pulled upon the more 
secure becomes its grasp. Its formation is best conveyed by observing Figs. 47, 48. 

Sutures. 

Sutures are employed in various forms according to the necessity of 
the individual case or the preference of the operator. Those in most 
frequent use are : 



Fig. 50. 



Fig. 51. 





Fig. 52. 
1 





Continuous suture. Interrupted suture. Modified plate suture, using gauze instead. 

Fig. 53. 

Fig. 54. 

Fig. 55. 





Modified quill suture, using gauze. Billroth's chain-stitch. Transfixion suture. 

la) The continuous suture (Fig. 50) is made by passing the needle in at one side 
of the wound and out through the other at an opposite point, when the suture is 



MINOR SURGERY AND BANDAGING. 217 

tied : the needle is again inserted into the side first penetrated and brought out 
upon the opposite side. This process is repeated until the wound is closed, when 
the double thread is tied with single thread into a square knot. This suture can 
be quickly placed, and if done with due care leaves a good scar. It is easy to 
strangulate the lips of the wound if more than moderate force be employed. 
Furthermore, unless the wound be quite dry the continuous suture requires that 
drainage be coincidently employed, as wounds thus closed are too tight to permit 
much escape of fluid from underneath. In long wounds it is well to tie the suture 
at varying intervals to avoid giving way of the entire suture should a' part fail. 

(b) The interrupted suture is the form most commonly employed. It is made 
by passing the needle through the tissues from one side to the other at an opposite 
point; the suture is then tied with an appropriate knot and cut off. The process 
is repeated as often as necessary, the sutures being from one-quarter to one-half an 
inch apart according to the tension. 

(c) The plate, transfixion, and quill sutures are shown in Figs. 52, 53, 55, and 
require no special description. They are all useful where tension is to be overcome 
or close approximation is required. Gauze makes an admirable substitute for the 
plate or quill. 

(d ) The Lembert suture is used in intestinal surgery. It includes all the coats 
of the intestine except the mucous. When the sutures are tied the serous surfaces 
are approximated. The sutures should be placed about one-eighth of an inch 
apart. 

(e) The Czerny suture brings the edges of the wound directly into apposition, 
but is employed only in intestinal suture. 

Secondary sutures are used in cases where from hemorrhage or 
expected suppuration the surgeon has been compelled to pack the cavity 
with gauze. The sutures (of non-absorbable material) are placed, but 
not drawn so as to coapt the edges of the wound. After a few days the 
packing is removed and the sutures tied, so as to bring the lips of the 
wound into apposition. 

Removal of Sutures. — Sutures are usually left in place from four to 
nine days : the time varies with the vascularity of the region and the 
tension. The knot should be seized with dressing-forceps and pulled 
upward and to one side, when the suture will show the part previously 
just underneath the skin and easily recognizable by its bleached appear- 
ance and moist condition. This is divided with appropriate scissors in 
the moist part, and the suture removed with the forceps previously 
applied to the knot. This detail of cutting through the moist part of 
the suture should be observed, as by dragging a dried part of the suture 
through the wound the latter may be easily infected. 

Transfusion and Infusion. 

The object of these procedures is to give bulk to the blood in the 
vessels from which it has been in part withdrawn through hemorrhage, 
to add nutriment, and to furnish red blood-corpuscles to the blood. 
That the two latter effects are ever produced is very doubtful. The 
giving of additional bulk is of unquestioned efficacy. 

The transfusion of blood, either directly or indirectly, from an 
animal or a human being into an exsanguinated person is to be men- 
tioned only to be condemned . It has been proven beyond doubt that the 
injection of defibrinated blood into the circulation is a dangerous pro- 
cedure. After a few days the red corpuscles injected die, haemoglobin 
is set free, and quickly causes destruction of the white blood-corpuscles, 
with formation and accumulation of fibrin-ferment, and not infrequently 
death of the individual. 



218 SURGICAL PROCEDURES. 

Direct transfusion is much less dangerous, but impracticable, as it is 
commonly difficult to find one ready to donate the blood. Furthermore, 
the blood may coagulate in the conducting tube, and under any circum- 
stances it is doubtful whether the red corpuscles thus injected retain 
their vitality. 

It seems, therefore, needless to describe the technique of transfusion, 
which is attended with so many dangers, and for which the infusion of 
a normal 0.6 of 1 per cent, saline solution may be more safely and 
advantageously substituted. A good formula is aq. destil. 1000, sodii 
chloridi 6.0, sodii carb. 1.0. This should be sterilized, warmed to 42° C, 
and rendered alkaline by the addition of one drop of sodium hydrate 
(sat. sol.) to every half-litre of the solution. Ludwig suggests the 
addition of from 3 to 5 per cent, of sugar to the alkaline solution, 
claiming that the addition of the sugar adds nutritive value, increases 
endosmotic action, whereby the blood absorbs the parenchymatous fluids 
more readily, and furthermore preserves the red blood-corpuscles from 
destruction better than the plain solution. The apparatus required con- 
sists of a glass funnel with rubber tube attached, which, in turn, is con- 
nected with a glass cannula. In order that the pressure exerted by the 
infused solution should not exceed that in the large veins the flask 
should be held a few inches above the level of the opening in the 
vein. Eighty or ninety cubic centimetres should be injected each 
minute until from 500 to 1500 c.c. have been used, according to the 
individual ease. The quality of the pulse will indicate when sufficient 
has been injected. Kneading of the abdomen favors diffusion of the 
solution. 

An admirable and efficient substitute for the above-described method is the 
subcutaneous infusion of the same solution, which is prepared, sterilized, and 
warmed as previously mentioned. This is then injected under the skin with an 
appropriate needle in amounts varying in all from 500 to 1000 c.c. This is often 
spoken of as hypodermoclysis. 

The anterior abdominal wall and the thighs are good regions in which to inject 
the solution. Massage helps the absorption of the fluid. 

Catheterization. 

Catheters are used chiefly to withdraw urine from and to wash out 
the bladder. Three kinds are in common use — viz. the metal, gum, and 
flexible — each of which has its distinctive advantages. In addition there 
are special forms, such as the prostatic, the elbowed (catheter Coude), 
and the olivary. 

The technique of catheterization varies with the form employed and 
the condition of the urethra. In the following brief description a normal 
urethra and a stiff catheter are presupposed : Having placed the patient 
preferably in the recumbent position, and having selected a good- 
sized catheter (No. 24 French) which has been previouslv made aseptic, 
well warmed, and thoroughly oiled, the operator holds the same between 
the thumb and forefinger of his right hand. Resting the little finger of 
the same hand uponthe patient's abdomen at or just beneath the umbil- 
icus, the catheter is inserted into the meatus, when the penis is slipped 
over the catheter as far as it can be made to go. (This procedure has 
the advantage of rendering the urethra smooth by obliterating the folds 



MINOR SURGERY AND BANDAGING. 219 

of the mucous membrane.) The catheter is then carried from its hori- 
zontal to a vertical position, when by pressing slightly downward and 
at the same time depressing the shaft between the thighs of the patient 
the instrument will usually glide into the bladder. 

Cleansing of Catheters. — Catheters should be kept in a strictly 
aseptic condition, otherwise inflammatory troubles, such as urethritis 
and cystitis, are prone to occur. After using, the catheter should be 
thoroughly rinsed in clean water, care being taken to remove all clots 
or debris from the bore of the instrument. (That portion of the cathe- 
ter between the eye and the tip is most liable to be insufficiently 
cleansed.) If running water lie not at hand, water may be forced 
through the catheter with a syringe, and considerable pressure should be 
used to ensure dislodging of the material contained within. This done, 
it should be followed with some antiseptic solution, such as carbolic-acid 
solution, 1 : 20, Condy's fluid, etc. 

Metal and glass catheters have the advantage that they may be sterilized by 
boiling. Other catheters after lying for twenty minutes in the antiseptic solution 
may be carefully dried and laid away for future use, wrapped in some impervious 
material like rubber tissue, oil silk, and the like, (ilass catheters may be kept 
in the antiseptic solution permanently. 

Normal Obstacles to Catheterization. — The novice may encounter 
several points along the normal urethra which tend to prevent the 
further passage of the instrument : 

1st. The catheter may catch in the fossa naviculars, an accident 
which may be easily avoided by keeping the tip close to the floor of the 
urethra during the first part of its passage. 

2d. It may be stopped at the triangular ligament. When this occurs 
the catheter should be withdrawn a little and the tip made to hug the 
roof of the urethra. 

3d. Fahc passages, previously made by using misdirected and excess- 
ive force. These are often difficult to avoid, but can usually be circum- 
vented by keeping the tip of the catheter close to the side of the urethra 
opposite the opening of the false passage. 

4th. The neck of the bladder may form an obstacle, under which cir- 
cumstances withdrawing the stylet a little, and thus tipping up the end 
of the catheter, will usually cause it to ride over the urethral floor into 
the bladder. 

Untoward Effects sometimes following- Catheterization. — These 
are both local and constitutional. Chief among the local effects we 
have — 

1st. Pain. — This is usually severe in nervous persons upon whom 
the catheter is passed for the first time. It may be mitigated by exer- 
cising gentleness and thoroughly oiling the instrument. A 4 per cent. 
solution of cocaine may be previously injected if deemed necessary or 
advisable. 

2d. Hemorrhage. — When this occurs it is rarely serious, and ceases 
soon after withdrawal of the instrument. If ordinary care has been 
used and hemorrhage follows, it usually denotes a pathological condition 
of the urethral mucous membrane. 

3d. False Passages. — As before said, these are usually due to mis- 
directed and excessive force, but may occur from very slight pressure 



220 SURGICAL PROCEDURES. 

when the mucous membrane has been congested for a long time from 
previous disease. Their occurrence may be recognized by the sudden 
giving way of previous resistance, sudden pain, followed by a sensation 
of grating appreciable alike to patient and operator. Further confirma- 
tion may be gained by noting any deviation of the handle of the catheter 
from the median line, by feeling the tip out of the middle line upon 
rectal palpation, and by the fact that no urine escapes. False passages 
may be avoided only by exercising the greatest gentleness and intelli- 
gence in manipulation. 

4th. Extravasation of Urine— This occurs in connection with false 
passages alluded to, and the prevention of the latter implies avoidance 
of the former. 

5th. Inflammatory conditions, such as abscess, urethritis, prostatitis, 
and cystitis, not infrequently result from the use of unclean catheters, 
mere mention of the cause, uncleanliness, indicating how best to avoid 
the condition. 

Constitutional Conditions. — The more common constitutional 
conditions may be traced to the effects of catheterization upon the ner- 
vous centres or to sepsis. Of the former we have, chiefly — 

1st. Syncope, Retention, and Suppression of Urine. — The use of 
cocaine and the recumbent position, combined with the greatest gentle- 
ness during the passage of the catheter, will do most to prevent or 
mitigate these unpleasant and sometimes dangerous effects. 

2d. Urethral Fever. — This is believed by some to be of nervous 
origin, by others to be due to the absorption of toxic alkaloids. The 
use of measures similar to those employed in the case of syncope are 
usually of pronounced value. 

3d. Pycemia. — This may occur even with the formation of meta- 
static abscesses, and is usually due to infection from without. The 
writer has seen one case of purulent synovitis of the knee-joint result 
from the use of an unclean catheter ; a.t least this seemed to be the only 
solution of the origin of the trouble, inasmuch as commoner causes of 
this affection could be pretty safely excluded. 

Artificial Respiration. 

There are various methods of producing artificial respiration, some 
of which accomplish the result through pressure upon the thorax, others 
bv means of direct inflation of the lungs. Of the former methods, those 
in most common use are Sylvester's, Marshall Hall's, and Howard's. 

Of these, Sylvester's is the simplest and easiest of execution. This method 
makes use of the arms as levers to expand the chest through the medium of the 
muscles which pass from the arms to the chest-wall, the origin and insertion of 
these muscles interchanging at each step. The patient is laid upon his back with 
the shoulders somewhat elevated by a pillow or cushion placed under them, the 
neck extended, and the head thrown back. The tongue may be drawn forward 
by an assistant if necessary. Foreign bodies, including water, must be removed 
from the pharynx. The surgeon should then seize the forearms just below the 
elbows and carry them over the patient's head as far as they can go. This action 
expands the thorax. A little extra jerk when the arms are at their highest point 
increases the efficiency of the movement. The arms having been thus held about 
two seconds, they should be brought down to the sides of the thorax and pressed 
firmly against the same for two seconds, when they are again elevated, and the 



MINOR SURGERY AND BANDAGING. 



221 



entire procedure repeated until no longer necessary. Pressure against the liver 
upward assists in emptying the lungs of their contents. The number of complete 
movements in a minute should equal that of normal respiration (sixteen to eigh- 
teen). If the patient be small, it is important that the feet be firmly held to 
prevent the body being pulled forward when the arms are carried upward. Should 
this occur, the efficiency of the procedure in expanding the thorax will be much 
diminished. 

Marshall Hall's method is practised as follows: The patient is rolled from the 
position on his back to that on his side ; the uppermost arm is pulled forward and 
pressure made directly upou the side of the thorax to expel the air from the lungs. 
The body is then rolled over on to the back, which movement causes respiration. 
The process is repeated as often as sixteen or eighteen times per minute. The 
method is not as efficient as that of Sylvester. 

Howard's method is best described in the words of its author : 1. Instantly turn 
patient downward, with a large firm roll of clothing under stomach and chest. 
Place one of his arms under his forehead, so as to keep his mouth off the ground. 
Press with all your weight two or three times, for four or five seconds each time, 
upon patient's back, so that the water is pressed out of lungs and stomach and 
drains freely out of mouth. Then, 2, quickly turn patient, face upward, with roll 
of clothing under back just below shoulder-blades, and make the head hang back 
as low as possible. Place patient's hands above his head. Kneel with patient's 
hips between your knees and fix your elbows firmly against your hips. Now, 
grasping the lower part of patient's naked chest, squeeze his two sides together, 
pressing gradually forward with all your weight for about three seconds, until 
your mouth is nearly over mouth of patient ; then with a push suddenly jerk your- 
self back. Rest about three seconds ; then begin again, repeating these bellows- 
blowing movements with perfect regularity, so that foul air may be pressed out 
and pure air be drawn into lungs, about eight or ten times a minute for at least 
one hour or until patient breathes naturally. 

The above directions must be followed on the spot the instant patient is taken 
from the water. A moment's delay and success may be hopeless. Prevent crowd- 
ing around patient ; plenty of fresh air is important. Be careful not to interrupt 
the first short natural breaths. If they be long apart, carefully continue between 
them the bellows-blowing movements as before. After the breathing is regular 
let patient be rubbed dry, wrapped in warm blankets, take hot spirits and water 
in small, occasional doses, and then be left to rest and sleep. 

The procedures based on direct inflation of the lungs include mouth- 
to-mouth inflation and forced respiration. 

Mouth-to-mouth inflation is practised in the following way : The tongue hav- 
ing been drawn forward, the operator applies his mouth directly to the mouth of 




Fell's apparatus for forced or artificial respiration. 



the patient, at the same time closing the nostrils. The operator then blows into 
the mouth of the patient, following this action with forcible pressure upon the 



222 SURGICAL PROCEDURES. 

walls of the thorax. This process should be repeated fourteen times in a minute. 
A good modification is to blow through a catheter which has been previously- 
passed through the larynx, or to pass an intubation-tube to which has been 
attached a rubber tube through which air can be easily forced. 

Forced respiration is effected by means of a bellows, the best form 
being that elaborated by Dr. George E. Fell of Buffalo. With it air 
can be forced into the lungs, either directly through the mouth and 
larynx or through a tracheotomy-tube. The writer has had occasion to 
test the efficacy of this apparatus a number of times, and cannot exag- 
gerate its usefulness. 

Whatever form of artificial respiration be made use of, such adjuvants 
as warmth, stimulation, and rubbing of the body in the direction of the 
venous circulation are not to be forgotten. 

Corns. 

Corns belong to the papillomata, and may be defined as an undue 
development of the cuticle attended with increased vascularity of the 
underlying cutis and more or less enlargement of its papillas. They are 
caused by intermittent or occasional pressure. There are two varieties — 
the hard and the soft — the former situated upon exposed parts like the 
little toe or the back of the toes, the latter being found between the toes 
and deriving their character from the moisture usually existing in this 
jjlace. For the same reason a soft corn grows more rapidly than a hard 
one. 

Corns are usually flattened and circular in shape externally, and extend 
beneath the skin in a conicular wedge-shaped manner. It is to this latter circum- 
stance, whereby the apex of the cone or wedge presses upon the sensitive papillae 
underneath, that corns owe their painful character. Old corns frequently have a 
bursa develop underneath them. This may become inflamed and even suppurate, 
a process usually very painful and occasionally terminating in ulceration, which 
may perforate deeply into the tissues, even to the bone. 

Treatment. — The treatment should combine prevention of recur- 
rence with destruction of the corn. When new and small, corns will 
commonly disappear on removing the pressure of tight or ill-fitting 
shoes and placing around the corn a felt ring (U-shape), whose edges 
shall take the pressure of the shoe from the corn. When it has existed 
for a long time a hard corn should be thoroughly softened with warm 
water, after which a solution containing salicylic acid 1 drachm, ext. 
henbane 4 grains, flexible collodion 1 ounce, may be painted upon the 
part once or twice a day. Iodine, potassium chromate, silver nitrate, and 
other similar agents have been recommended. Inflamed corns should 
be treated by elevation and rest of the part, together with antiseptic 
fomentations. If pus forms, it should be evacuated, great and almost 
immediate relief usually following. 

Bunions. 

A bunion is an enlarged normal bursa or one produced adventitiously 
by the pressure of an ill-fitting shoe. Bunions are usually found on the 
inner side of the great toe at the metatarso-phalangeal joint. When the 
shoe has its inner border slanting outward, as in very pointed shoes, or 



MINOR SURGERY AND BANDAGING. 223 

it is too short and narrow, the best conditions are present for producing 
a bunion. Another cause is prolonged continuous standing upon a weak 
tarsus, which produces flat-foot and the oblique outward direction of 
the .great toe which accompanies the condition. It may become much 
enlarged and inflamed, and not infrequently terminate in suppuration. 
Very commonly, too, the joint becomes prominent on its inner side from 
enlargement of the head of the metatarsal bone. In extreme cases the 
great toe mav lie at almost a risj-ht angle to the long axis of the foot and 
over or under the adjacent toe. In such cases the deformity is pro- 
nounced and the interference with walking quite marked. 

Treatment. — This is preventive or curative. Remembering the 
eti( ilogy of bunions, it is apparent that proper shoes are necessary. The 
inner side of the shoe should be almost straight, there should be suf- 
ficient width to permit the foot to spread normally, and the shoe should 
be sufficiently long. When inflamed the foot should be elevated and 
put at rest. Incision is indicated when pus is present. In the old and 
inveterate forms, -without much or any inflammation, a blister may be 
applied, and its counter-irritant effect maintained by rubbing in an oint- 
ment of biniodide of mercury, 10 grains to the ounce of lard. Where 
the head of the metatarsal bone is unduly enlarged and the deformity 
great, excision of a wedge-shaped piece of bone, followed by fixation of 
the toe in a normal position, is indicated. Except in very old and feeble 
subjects amputation is rarely called for. 

Ingrown Toe-nail. 

Two causes operate to produce ingrown toe-nails : one is the pressure 
of a shoe or tight stocking which is too narrow ; the other is the over- 
growing of the cuticle adjacent to the edge of the nail. This latter is a 
very common cause, which is frequently aided by the bad practice of 
rounding off corners when cutting the nail. In the milder grades of 
the trouble there is little to be seen on inspection except the overhang- 
ing cuticle. When, however, ulceration has occurred, the side of the 
nail may be covered with foul granulations which exude pus. The pain 
and inability to walk may be very great when the inflammation is pro- 
nounced. In some severe cases widespread cellulitis may be present. 

The therapeutic indications are to remove pressure either of the shoe 
or cuticle and to substitute healthy for unhealthy granulations. Patients 
with ingrown toe-nails should wear well-fitting shoes and stockings. 
When the cuticle overhangs it may be pushed back into normal place by 
inserting a small roll of cotton under the edge of the nail and along the 
border of the same. Adhesive plaster applied so as to draw the cuticle 
from the edge of the nail has proved of signal value in the writer's 
hands. In the more severe eases the granulations should be touched 
with silver nitrate or copper sulphate, or, better still, they should be 
curetted away and the remaining surface thoroughly disinfected and 
cauterized. Others, again, may only yield when to the above treat- 
ment is added continuous pressure and some astringent powder. This 
may be done by dipping a small hard roll of absorbent cotton into pow- 
dered lead nitrate and binding it over the granulating surface with 
adhesive plaster. Sometimes removal of the contiguous portion of the 



224 SURGICAL PROCEDURES. 

nail is indicated, but this procedure is rarely necessary if both patient 
and surgeon will exercise a little patience and employ treatment along 
the lines above indicated. 

Skin-grafting. 

The Thiersch Method. — In this method about half the thick- 
ness of the skin is used. It is removed by putting the skin on the 
stretch either with broad sharp retractors or by grasping the part so as to 
accomplish the same effect, when, with a keen razor previously wet with 
a sterile normal (.6-1.0 per cent.) solution of common salt, strips anywhere 
from one to twelve inches long are removed. These are transferred to 
the wound upon the razor-blade or a spatula, and spread evenly and 
closely upon the surface with probes. The preparation of the granu- 
lating surface for the reception of the grafts is of vital importance to 
success. It should have been made aseptic and healthy. When granu- 
lations are deep red or "raw beef" in color, with little or no pus, and 
cicatrization has already begun, we have the best surface for grafting. 
It is not necessary, however, to wait until this condition is present. 
Provided the surface be aseptic, the superficial granulations may be cur- 
retted off, a very light touch being sufficient to do this. It has been 
recommended to remove any line of cicatrization which may be already 
formed, as experience has shown that subsequently ulceration frequently 
occurs in just this place. All hemorrhage is to be thoroughly checked 
before the grafts are put in position. The after-dressing consists in first 
placing a layer of sterilized green protective or rubber tissue sufficiently 
large to cover the entire surface and overlap the edges a little. This is 
to be laid on evenly, and over this are applied gauze compresses satu- 
rated in the normal saline solution and absorbent cotton, all firmly held 
in place with a bandage. Gold- or tin-foil may be used in place of the 
protective or rubber tissue, and sterilized oil may be substitued for the 
saline solution. 

The oil dressing is certainly more convenient than the solution, with which 
the dressings must be kept constantly saturated to ensure success. Any dressing 
which sticks is apt to dislodge the grafts, their adhesion to the underlying surface 
in the first few days being very slight. No antiseptic solutions should come in con- 
tact with the grafts. The dressing should not be changed under four or five days, 
and should then be removed with the greatest care lest the grafts be disturbed. A 
similar dressing should replace the first, and not be discontinued under two weeks, 
after which some ointment may be used. The advantages of the Thiersch method 
are the rapidity of healing of extensive defects and the relative non-contractility 
of the new skin thus formed. 



Extraction of Teeth. 

There is, perhaps, no minor surgical procedure which requires for its 
proper completion a more thorough application of anatomical knowledge 
and more manual dexterity than the extraction of teeth. When one con- 
siders the frequency with which the average practitioner is called upon 
to perform the operation, it is apparent that he should possess sufficient 
knowledge to appreciate the dangers arising from the application of 
immoderate and misdirected force. 



MINOR SURGERY AND BANDAGING. 22fj 

Instruments Required. — The instruments required are forceps and 
the elevator. There should be at least five pairs of forceps, and, better, 
seven. (The more experienced, however, the operator the fewer the 
forceps needed.) The forceps have various shapes to meet the require- 
ments. The elevator is of use where the forceps cannot be applied, as, 
for instance, in troublesome stumps lying beneath the alveolar border. 

Method of Extraction. — To extract teeth properly the operator 
should bear in mind certain anatomical points. The teeth are arranged 
in the form of an arch in which each tooth is a keystone, it being nar- 
rower at the inner alveolar border than at the outer. It can therefore 
be dislodged most easily by force acting in a direction outward — ('. c. 
toward the check. Furthermore, the alveolar border is much thinner 
upon the outer than upon its inner side. (An exception must be made 
at the site of the third molar (wisdom) tooth.) The tooth should be 
seized with appropriate force upon the fang well beyond the crown. 
Pressure outward is then made, this frequently splitting the socket on 
the outer side and coincidently rupturing the periosteum on the inner 
side of the tooth. The pressure is then reversed and the tooth brought 
back into its original place, this motion causing the periosteum on the 
outer side to break. By quickly repeating these rocking movements the 
periosteum is entirely torn through and the socket sufficiently bent or 
split to leave the tooth free, when by adding a direct pull the tooth is 
extracted. Naturally, the technique varies somewhat with the tooth 
extracted and its situation, whether in the upper or lower jaw. In the 
upper jaw direct pressure upward permits the forceps to be easily 
applied to the fang. In the lower jaw the operator adjusts the forceps 
to the neck of the tooth and presses it down with the thumb of his left 
hand placed over it in the mouth, the fingers of this hand grasping the 
lower jaw firmly from below. 

Accidents from Extraction. — (a) Hemorrhage. — This may be 
severe enough to threaten life in those having a hemorrhagic diathesis. 
Ordinarily it is not of moment. 

The socket having been thoroughly cleared of clot, ice or ice-water may be put 
into it, followed, if necessary, by a cotton plug soaked in some astringent, such as 
persulphate or perchloride of iron, tannin, alum, and the like. This plug should 
be pressed firmly into the socket and reach its uppermost part, otherwise the pres- 
sure of the blood will quickly dislodge it: should plugging prove inadequate, the 
fine point of a Paquelin cautery may be used with advantage. Where the tooth 
that has just been extracted is at hand, it may be placed in the socket and pressed 
firmly in. This often succeeds admirably. 

(b) Dislocation or Fracture oftlte Lower Jaw. — These injuries should 
receive immediate treatment, the details of which will be found else- 
where. 

(c) Fracture of Opposing Teeth. — This results from slipping of the 
forceps or their sudden and unanticipated release from breaking of the 
crown, etc., whereby the forceps hit the teeth above or below, as the 
case may be. 

(d) Fracture of the Tooth Extracted. — When this occurs all pieces 
should be removed with appropriate forceps. Should the removal of the 
remainder of the fang require much bruising or breaking of the alveolus, 
it is better to postpone its removal until it has risen nearer the alveolar 
border. 

15 



226 SURGICAL PROCEDURES. 

{() Extraction of Healtliy Teeth. — This may happen through mis- 
take, or a healthy tooth may be pulled coincident v with one diseased. 
The socket should be cleansed and the tooth washed in warm water and 
replaced. After pressing it firmly into place, it may be retained by 
closing the teeth and maintaining this apposition with an appropriate 
bandage. 

(/) Forcing a Tooth into the Antrum of Highmore. — This accident is 
due to pressing too firmlv in the effort to grasp the fang. The tooth should 
be removed and the parts thoroughly cleansed to avoid inflammation and 
suppuration within the antrum. 

(g) Tearing of the Alveolar Border. — Careless application of the for- 
ceps is the usual cause. When slight the gum may be pressed into place. 
If more extensive, one or more stitches may be required. 

(h) Injury to the Inferior Dental Nerve. — This may occur as the result 
of dislocation of the lower jaw or from fracture. Perfect reposition of 
the parts is the treatment indicated. 

(<) Dropping of a Tooth or of Pieces of Instruments into the Larynx. — 
The result may be immediate suffocation, or, if the foreign body escape 
through the vocal cords, a septic pneumonia is apt to occur. To avoid 
this complication the operator should invariably make sure that the for- 
ceps have released the tooth previously drawn before again introducing 
them into the mouth. When the accident has occurred removal of the 
foreign bod}- is imperative, and may be accomplished by appropriate 
measures. 

Bandaging. 

The tendency in bandaging to-day is toward simplicity, and this is 
due in part to modern ideas of antiseptic and aseptic surgery and in part 
to the materials employed. 

The need for elaborate descriptions of the various methods of band- 



Fig. 5' 




Figure-of-8 bandage of leg 



aging different parts of the body does not seem to exist and therefore 
diagrams instead of verbal descriptions will be employed the latter 
being too complicated and indefinite to justify the space they occupy in 
the average text-book of surgery. ^ 

Among the materials used in bandaging may be included cotton 
cheese-cloth, crinoline, gauze, flannel, rubber, and' materials which havi 



MIX OR SURGERY AND BANDAGIXG. 



227 



been impregnated with plaster of Paris, starch, silicate of sodium, etc. 
In selecting a bandage one must have in mind the part to be bandaged, 
the amount of restraint and. support required, the length of time the latter 
is to be maintained, the effect upon the shin, the circulation of the part, 



Fig. 58. 



Fro. 59. 





Velpeau's bandage. 



Ascending spica bandage of the groin. 



and such other considerations as maybe indicated in individual cases. 
For instance, crinoline is easily impregnated with plaster of Paris, 
starch, or other stiffening material, and when so used has peculiar 
advantages in giving firmness to the dressing. Where moderate firm- 



Fig. 60. 



Fig. 61. 





Head-and-neck bandage. 



nesswith some elasticity is desirable cotton is a good agent. We employ 
bandages to give rest and support to affected parts, to retain splints and 
dressings, to prevent or reduce swelling, and to check hemorrhage. 

Bandages may be divided into three general classes — the roller, tri- 
angular or scarf, and special bandages. The roller bandage varies 



228 



SURGICAL PROCEDURES. 



in width and length according to the requirements in individual cases. 
It is employed as the mujlc or double roller, the former being the one in 
common use. It is usually employed upon the head and extremities, 
although applicable to other situations. 




Roller bandages are made in various sizes, the average being 2|- to 
3 inches by 7 to 8 yards. They may be made into rolls for use, either 
by hand or with appropriate apparatus found in instrument-stores. 




The method of applying a roller bandage varies with the region to 
be bandaged. Its application to an extremity, however, is sufficiently 
illustrative of its use in general, and maybe briefly described as follows : 
Bearing in mind the amount of firmness and support required, and that 
the pressure must be evenly distributed over the part, the roller is 



MINOR SURGERY AND BANDAGING. 
Fig. 66. Fig. 67 



229 




/:■ ■ 




T-bandage 



Kelly's bandage with pe 



seized with the right hand, the free end being detached with the thumb 
and fore finger of the left hand, the bandage unrolled for some three or 
four inches ; the free end is then placed upon the inner side of the limb, 
and the roller carried around it again and again, 
each time overlapping the one preceded by 
about half its width. Where the extremity 
is cone-shaped the reverse must be employed, 
this being done by turning the bandage on 
itself. This process is repeated until the part 
again becomes cylindrical or until the region 
is sufficiently covered. When the bandage has 
been applied the remaining free end is pinned 
to the underlying layers. 

The triangular or scarf bandage is sim- 
ple, efficient, and of wide applicability : it has 
proven of great value in emergencies upon 
the battle-field and elsewhere. 

Special bandages include the many-tailed 
H and T bandages, all of which are found use- 
Barton's head bandage as em- ful in certain regions of the body, a few tvr>- 

ployed for suspension in apply- ., , ,.° , „. •''_„ „_ ;Jjf 

mg piaster-of-Paris bandage. icaJ examples being shown in Ilgs. 66, 67, 68. 




CHAPTEE XIX. 
ANAESTHESIA AND ANESTHETICS. 
By H. A. Hare, M. D. 



The word ancesthetic was first suggested, as a suitable term for a drug which 
removed the sense of pain, by Oliver Wendell Holmes in November, 1846, the 
discovery of this property of ether or ethyl oxide having been put to practical 
application by Dr. Morton, a dentist of Boston, on September 30, 1846. The first 
public use of ether for surgical purposes was made by Warren on the 16th day of 
October, 1846, in, the Massachusetts General Hospital. Although Long of Georgia 
caused anaesthesia by ether as early as 1842, and Jackson. of Boston asserted that 
it was he who made the discovery, and not Morton, it has been decided by com- 
petent judges that the latter (Morton) really deserves the credit for the general 
introduction of ether as an anaesthetic for surgical purposes. In November, 1847, 
just one year after Morton's discovery, Simpson of Edinburgh first noted the 
anaesthetic power of chloroform on himself and some friends. Since this time no 
other substance designed to produce general surgical anaesthesia has been intro- 
duced which approaches the usefulness of these two drugs, and they remain the 
almost universal anaesthetics of the day, if we except nitrous-oxide gas, the appli- 
cations of which are very limited. 

Before discussing the action and uses of ether and chloroform it is 
proper to consider several general facts concerning both of them and the 
use of anaesthetics in general. The first fact to be borne in mind by the 
surgeon is that these drugs are not to be used except when really needed, 
and when employed are to be chosen with distinct ideas as to their indi- 
vidual peculiarities and indications in each case. A patient under the 
effect of so powerful a drug that consciousness is destroyed is nearer 
death than the ordinary human being, since the primary depressing influ- 
ence upon the high nervous centres may speedily pass to the lower vital 
centres in the medulla oblongata. 

Again, the day is fast approaching, if not already here, when the sur- 
geon must choose the anaesthetic to be used in each individual, just as 
he directs one or another cardiac stimulant in circulatory failure accord- 
ing to the end to be obtained. No one should use ether exclusively or 
chloroform exclusively, for there are, as we shall point out later on, indi- 
cations and contraindications governing the use of both. 

Another point to be remembered is that the skill of the anaesthetizer 
does not consist so much in getting his patient under in a short time as it 
does in producing surgical anaesthesia gently, cmily, and tenderly, so that 
the heart and mind will not be disturbed by suffocation, fright, strug- 
gling, or overdosing with the drug. Many anEesthetizers think that their 
responsibility ceases as soon as the patient returns to consciousness, but 
nothing is more erroneous, for much of the post-anaesthetic distress, the 
vomiting, the bronchitis, the pulmonary congestion, and the condition of 
anuria may be avoided by properly giving the drugs we are discussing. 

230 



ANESTHESIA AND ANESTHETICS. 231 

It is quite as much a duty to avoid excessive drugging under these circum- 
stances as it is to avoid overdosing when digitalis or any other powerful drug is 
used, for the skill of the physician consists not only in knowing what to give, but 
in knowing when enough has been used to produce the results sought for. The 
dose of the anaesthetic is to be governed by the response of the individual, and the 
physician who drowns his patient with chloroform or ether is producing poisoning 
and not therapeutic anaesthesia. 

Every person to whom an anaesthetic is to be given should be 
examined to determine the condition of the heart and blood-vessel x, and, 
if time permits, the urine should be examined repeatedly for several 
days prior to the operation to determine the condition of the kidneys, 
since the danger of artificial anaesthesia is greatly increased by the pres- 
ence of disease of the heart, blood-vessels, or kidneys. Immediately 
before the drug is given careful inquiry should be made to discover 
whether the patient has some foreign body in the mouth, such as false 
teeth, tobacco, pins, or, as is frequently the case to-day, chewing-gum, 
which if not removed may cause grave difficulties by falling to the back 
of the mouth and so obstructing the air-passages. The patient also should 
be asked whether he or she has ever taken an anaesthetic before, and 
if so whether it had any untoward effect. In this manner idiosyncrasies 
may be discovered which will enable the physician to be on the lookout 
for accidents. 

An anaesthetic should never be given without the consent of the patient or his 
friends if it be possible to obtain it, but in an emergency case, should no friends be 
at hand and the patient incompetent to decide for himself, then the surgeon may 
fearlessly take the responsibility of giving the drug he deems safest. Care should 
always be taken when a woman is to be anaesthetized that a reliable assistant, pref- 
erably a female nurse, is present, both for the comfort of the patient and for pro- 
tection of the physician, since cases are on record where the patient has accused 
her medical attendant of assault while he had her under the effects of the drug, 
either for the purpose of blackmail or because in the anaesthetic sleep she has 
experienced an orgasm of which the anaesthetizer has appeared to be the cause. 

Leaving for later on the discussion of the relative safety of the minor 
anaesthetics, we come to a study of the safety of ether and chloroform. 
There has been much difference of opinion as to the relative safety of 
these drugs, but at present the profession is practically a unit in recog- 
nizing that ether is the less dangerous by far, although a large number 
of eminent men still employ chloroform to the exclusion of ether, on 
the ground that when given with care accidents are almost unheard of. 
When we remember that in many eases the giving of the anaesthetic is 
entrusted to the least experienced professional man present or to a nurse, 
the relative danger of ether and chloroform is a factor of importance. 

Published statistics as to the relative safety of ether and chloroform 
during anaesthesia are open to many objections and vary with startling 
discrepancies, so that even the largest collections of figures are to some 
extent at fault. The chief fault is that in none of the statistics are the 
deaths really resulting from the direct action of the drugs separated 
from those in which it has only needed the action of a powerful sub- 
stance to upset the balance of function in some diseased organ and so 
produce a fatal ending. 

The following table shows the approximate death-rate from ether and chloro- 
form, and the variations in statistics according to different collectors: 



232 



SURGICAL PROCEDURES. 



ETHEK. 

1 death in 23,204 cases. 
1 death in 16,542 cases. 
(314,738 cases), 1 death 

14,987 cases. 
1 death iii 23,204 cases. 
(14,581 cases), 1 death 

4860 oases. 
1 death in 23,204 cases. 
1 deatli in 16,677 cases. 
1 death in 23,204 cases. 
(42,141 cases), 1 death 

6020 cases. 



CHLOROFORM. 

1 death in 5860. 

(524,507 cases), 1 death in 

3258. 
1 death in 2873. 
(12,368 cases), 1 death in 1236. 



1 death in 3749. 
1 death in 2873. 
(201,224 cases), 

2286. 
1 death in 3000. 



1 death in 



no death in 2900 cases. 



Andrews, 

Julliard, 

Ormsby, 

Roger Williams, 

Lee, 

Medical News collection, 

Coles, 

Gurlt, 

Richardson, 
Ziegler, Vogel, Korte, 
and Esmarch, 

In studying this table the fact must be constantly borne in mind that 
one or two cases of heart disease or advanced renal disease, causing 
" death from the anesthetic," so called, may seriously alter the percent- 
age, but the preponderance in favor of ether is so great as to settle the 
question of relative safety for ever. 

It is only fair to state, in addition to these figures, that Oilier has collected 
40,000 etherizations without a death, Poncet 15,000, Tillier 6500, and Chabot 730. 
Similarly, McGuire of Virginia claims 28,000 ehloroformizations without a death, 
Von Nussbaum 40,000, and Lawrie of India about 30,000. 

When ether is first inhaled, even when well diluted with air, it is apt 
to cause a sensation of oppression or even of suffocation, which can be 
overcome by gradually increasing the strength of the vapor and by the 
aid of the patient, who, if intelligent, will often voluntarily overcome 
his shallow breathing and take deep inspirations of air laden with the 
vapor. 

This primary sensation of suffocation, with that which often comes on just as 
the patient is about to pass into unconsciousness, can nearly always be avoided, at 
least in part, by not giving the drug too freely, or rather by allowing enough air 
to enter with the vapor of the ether to prevent cyanosis. 

Only in the most hurried cases is it proper to pour the ether on the 
inhaler and then hold it tightly over the patient's face at the very begin- 
ning of the administration. Not only is such a method harsh and 
calculated to frighten the timid, but it is capable of straining the heart 
through congestion arising from the struggles of the patient, and, if am* 
weakness of the blood-vessels is present, may cause their rupture by the 
rise of arterial pressure produced by the drug, the struggling, and the 
partial asphyxia. 

Very commonly there follows after this period of reflex irritation a 
few long-drawn breaths, and then fixation and immobility of the chest 
ensues, so that for thirty seconds or a minute it would seem as if the 
patient was forgetting to breathe, and then a deep respiration like a long- 
drawn sigh ensues, followed by a rapid, deep breathing, which, by reason 
of the large amount of ether inhaled, either renders the patient partially 
anaesthetic and ready for a minor and brief operation or more commonly 
it initiates what is known as the stage of excitement, during which the 
patient shouts, sings, cries, swears, or fights, according to his tempera- 
ment and previous condition. This stage rarely lasts for more than a 
few minutes, and then the patient actually passes into the complete 



ANESTHESIA AND ANESTHETICS. 233 

anaesthetic condition and is ready for the surgeon's method. The puke. 
from the first under ether is accelerated, although in some cases, where 
because of fright or other reason the pulse has been very rapid, it may 
be slowed by the steadying or stimulant effect of the drug. The respi- 
rations when" once the patient is anaesthetized are more rapid and deeper 
than in health, and the skin is dry and warm, though often flushed, 
particularly about the face and neck. 

With the development of well-marked muscular relaxation snoring 
or stertorous breathing comes on, and the increased secretion of mucus 
and saliva due to the irritant effects of the ether increases the noisiness 
of the respiratory cycle. If the ether be pushed beyond all therapeutic 
bounds, the pallor of the surface changes to a deathly lividity. while 
the skin becomes cold and perhaps relaxed and moist, the pulse fails ; 
the respiration is gradually extinguished from intoxication of the res- 
piratory centre, so that death ensues from this cause. The muscular 
system is totally relaxed and flabby, but the heart continues to beat 
feebly for some moments after the breathing ceases. In producing its 
effects ether depresses first the perceptive and intellectual cerebral centres, 
next the sensory side of the spinal cord, next the motor side of the cord, 
then the sensory and motor portions of the medulla oblongata; and with 
this depression death ensues. 

Turning from the general effects produced by ether to its therapeutic 
application, we find that it has certain advantages and disadvantages. 

The chief advantage connected with its use is that it is by far the 
safest anaesthetic substance so far discovered for the production of 
anaesthesia during prolonged surgical operations. The patient passes 
under its effect, as a rule, quite rapidly, and once anaesthetized needs 
but a small additional quantity to keep him under its influence. 

Besides the lethal effects of ether we have still before us a considera- 
tion of the non-fatal accidents which may occur under its influence and 
the sequela which follow its use. The accidents which occur during the 
use of ether are rarely very alarming, and consist chiefly in arrest of 
respiration through depression of the respiratory centre by the excessive 
action of the drug, or stoppage of breathing caused by an accumulation 
of mucus or some foreign body in the air-passages. The appearance of 
the face must be the guide under such circumstances as to the methods 
of relief to be employed. If the face is, as usual, very much flushed or 
dusky or cyanotic, artificial respiration is to be resorted to by the 
general methods described later in this article under the treatment of 
anaesthetic accidents. If it is very pede, thereby indicating cardiac as 
well as respiratory failure, then the artificial respiration should be aided 
by inversion of the patient and the injection of stimulants. 

The sequeke following etherization are chiefly pulmonary and renal, 
and it is probable that a certain number of deaths result from these 
secondary manifestations of the action of this drug. As will be pointed 
out when discussing the choice of an anaesthetic, bronchitis, pulmonary 
congestion, and catarrhal pneumonia often seem to be produced by it. 
Very rarely, even croupous pneumonia has ensued. 

Renal disorders from the use of ether rarely arise in persons with 
primarily healthy kidneys, and consist in varying degrees of irritability 
and inflammation up to that which results in the condition of anuria 



234 SURGICAL PROCEDURES. 

which is the most serious and fatal complication which can arise, because 
death is nearly always assured by this symptom, and because it is prac- 
tically irremediable. 

The use of ether in the case of diabetics is dangerous, and Becker 
has found in 188 cases of etherization acetonuria in no less than two- 
thirds. Baxter has reported a death from ether given to a diabetic, 
who passed into coma from the anaesthetic state. 

An important fact in this connection with the development of catar- 
rhal complications after ether is that surgeons, as a rule, are careless of 
the maintenance of the body-temperature during an operation. In a series 
of studies made by the writer some years since it was found that even 
under brief operations the temperature might fall from 1° to 4° F., 
this fall being due in part to the evaporation of the ether and to the 
depression of the vital processes. Naturally, irritation of the respiratory 
mucous membrane plus exposure to cold will predispose to pulmonary 
complications, and the chilling of the surface produces pulmonary and 
renal congestion. 

Vomiting following the use of ether is unfortunately very commonly 
seen, and is practically a constant sequel in those who have inhaled the 
drug upon a full stomach. It is supposed to be due to irritation of the 
vomiting centre and to the swallowing of saliva and mucus. It is to 
be avoided to some extent by giving the drug on an empty stomach. 
Once developed, the vomiting is to be treated by counter-irritation in 
the form of a mustard plaster over the epigastrium, by the use of one- 
grain doses of acetanilide every hour, 1 or by rectal injections of bromide 
of sodium and laudanum in starch-water. Sometimes washing out the 
stomach with a stomach-tube gives relief. For persistent singultus 
drachm-doses of Hoffman's anodyne are very effective. 



Chloroform. 

This drug was discovered practically simultaneously by Guthrie in America 
and Soubeiran in France. It is a colorless, transparent, volatile fluid of a hot 
sweetish taste and rather pleasant odor, having a specific gravity of 1.491 at 60° F. 
It is liable to decomposition in the presence of sunlight, and generally contains 
about 1 per cent, by weight of alcohol to retard this change. A pure chloroform 
has been made by a freezing process by Pictet, which is said to be less liable to 
decomposition than that made by the ordinary method. Great importance is to 
be attached to the use of pure chloroform, as many of the fatal accidents are 
believed to be due to the use of a poor article. It should be absolutely neutral, 
and when evaporated in a watch-glass should leave no residue of any kind or any 
strong odor. 

When chloroform is inhaled by the healthy man there may be for a 
moment a slowing of the pulse and a rise of arterial pressure, due in 
part to the cerebral excitement of the patient and to the irritation of 
the respiratory mucous membrane produced by the anaesthetic vapor, 
which may also reflexly cause cardiac inhibition. This condition is, 
however, very fleeting, and is replaced by a pulse more rapid than nor- 
mal and one which is less powerful. The arterial tension is generally 

1 A very useful formula in this connection is one composed of 1 grain of acetanilide, 
1 grain of monobromated camphor, and 1 grain of citrated caffeine, given every hour for 
six or eight doses. 



ANAESTHESIA AND AN /ESTHETICS. 235 

decreased. The respiration may for a very brief period be partially 
arrested, but this symptom is often entirely absent, and never so marked 
as when ether is given. 

The pupils are primarily a little dilated, but permanently contracted 
during full anesthesia. If they suddenly dilate during the ancesthetie pe- 
riod, death is imminent. In other words, relaxation of the iris under 
chloroform is a part of the relaxation of death. 

Should the patient struggle violently, the drug must not be pushed, 
and it is to be borne in mind that the use of the drug is more apt to 
cause sudden death if the patient be an athlete or a drunkard. 

The action of the chloroform in producing anaesthesia is identical with that 
of ether, acting first on the perceptive centres, then on the intellectual centres, and 
then on the motor centres. Care should also be taken while it is being used that 
the bodily heat does not fall. 

The effect of chloroform on man and lower animals has been studied with 
extraordinary care all over the world, and much conflicting testimony exists con- 
cerning it. The writer has embodied his views as to its safety in his report to the 
Governor of Hyderabad, India, and believes that the medium ground there taken 
is the correct one; and it is an interesting fact that Randall and Cerna of Galves- 
ton undertook a series of studies designed to contradict these conclusions, but in 
the end endorsed them. 

The writer very positively asserts that chloroform practically always 
kills by failure of respiration when administered by inhalation up to the 
point of producing poisoning, provided — and this provision is most 
important — that the heart of the anaesthetized is healthy and has not 
been rendered functionally incompetent by fright or violent struggles, 
or, again, by marked asphyxia. There can be no doubt that chloroform 
always impairs the circulation by causing a fall of blood-pressure by its 
depressant effect on the vasomotor system and upon the heart, and for 
this reason any idiosyncrasy or disease might readily result in a cardiac 
death from it. 

The accidents which may result during the use of chloroform will 
be discussed under the head of the Treatment of Accidents under Anaes- 
thetics. We shall now speak of the sequelae which may follow the use 
of chloroform. The most important of these is renal disorder, for pul- 
monary complications are very rare indeed. 

The truth of the matter seems to be that both ether and chloroform 
possess the power of distinctly irritating the kidneys, but it also seems 
to be undoubtedly true that, as chloroform acts as an anaesthetic in very 
small quantities, it is always to be the anaesthetic of election where ope- 
rative procedures are demanded in the face of renal complications. 

Vomiting following the use of chloroform is comparatively rarely 
seen, although nausea may be present in susceptible persons. 

Ethyl Bromide. 

The position of bromide of ethyl as an anaesthetic is still undecided. 
Originally introduced with much promise, it soon fell into disrepute 
because of several deaths which took place under its use, but within the 
the last few years it has been more largely employed, notably by Mont- 
gomery of Philadelphia. 

The advantages possessed by ethyl bromide are its speedy action, the 
patient becoming anaesthetic in a very few moments, and the equallv 



236 SURGICAL PROCEDURES. 

rapid passing away of its effects, the patient returning to consciousness 
almost at once when the drug is removed. Other advantages are that it 
produces no disagreeable after-effects. Generally the patient is able to 
walk perfectly in a very few minutes without much vertigo or nausea. 
Sometimes during its inhalation tonic spasm of the muscles with rigidity 
develops. 

The proper manner of using bromide of ethyl is to pour two or three 
drachms on a well-made ether cone, and then to give as pure vapor of 
the drug as possible, with little air. If much air enters, the anaesthesia 
is imperfect and the operation of the drug unsatisfactory. Sometimes, 
even if the drug be well given, a temporary tonic contraction of the 
muscles comes on and is more or less persistent. 

A. 0. E. Mixture. 

Various mixtures of chloroform and ether have been made and used 
for the production of anaesthesia. The most commonly used of these is 
the so-called " A. C. E. mixture," composed of alcohol, chloroform, and 
ether. It was thought that, as alcohol and ether stimulated the heart 
and chloroform depressed it, a combination of the three drugs would 
antagonize each other on these vital points while acting to produce anaes- 
thesia. Unfortunately for this theory, the drugs differ so in volatility 
that they are not absorbed simultaneously in equal amount, and the 
alcohol tends to produce bronchial irritation and prolonged intoxication. 
The mixture is not to be commended. 

Nitrous-oxide Gas. 

This gas is the safest and most rapid general anaesthetic that we pos- 
sess. As its anaesthetic influence does not last more than a minute, and 
in many persons not more than fifteen to thirty seconds, it can only be 
used for very brief minor operations, and as a matter of fact is seldom 
used except by dentists for the production of anaesthesia during the 
extraction of teeth. 

When the gas is given to man there may be a momentary increase in sensitive- 
ness, followed by analgesia, during which time little feeling exists, although the 
patient generally knows what is being done. Immediately after this he becomes 
absolutely unconscious and jerking or twitching of the muscles may occur. The 
superficial reflexes are abolished, but the knee-jerk is present and ankle-clonus is 
often present. Often the bladder and rectum are emptied, but vomiting rarely 
occurs. The subsequent symptoms are tinnitus aurium, headache, and dimness of 
sight. 

Sometimes nitrous oxide is used to anaesthetize a patient when the 
surgeon is in a hurry, unconsciousness being then preserved by the addi- 
tional use of chloroform and ether. 

Nitrous oxide ought not to be given to persons with fatty heart or athe- 
romatous vessels. 

The Choice op an Anesthetic. 
As already stated, ether and chloroform are still the anaesthetics of 
election for all general purposes. Nitrous oxide is only suited to minor 
and brief operations, and is difficult of use because of the bulk of its 



ANAESTHESIA AND ANAESTHETICS. 237 

containers : the other anaesthetic substances are either dangerous or, like 
ethyl bromide, only suited for the production of rapid passing effects. 

(1) On general principles ether is to be preferred to chloroform, 
whenever no contraindication to its use exists, because of its greater 
safety. This is particularly the case where an inexperienced person is 
to give the anaesthetic. It is, however, inferior to chloroform in very 
young children and in persons who have bronchitis, because of its irritant 
effect on the respiratory mucous membrane. Renal disease also renders 
ether a dangerous anaesthetic, because the kidneys are irritated by it, 
and, again, marked atheroma or aneurism contraindicates its use, since 
it greatly increases arterial- pressure and so tends to produce arterial 
rupture. 

Similarly, it will- be found best not to attempt the use of ether in hot 
climates, because of its volatility, nor on the battlefield, where rapidity 
of action is essential and where its bulk is so great as to make its use 
difficult. 

Ether should never be given in the presence of a naked flame, unless 
the flame be high above the cone, as the vapor is inflammable. The 
vapor of ether being heavier than air, gravity causes it to sink to the 
floor. 

(2) Chloroform is not as safe as ether for the average case, but is to 
be preferred, where ether cannot be used, to any similar drug. It is to 
be preferred in hot climates (where ether is inapplicable), and here a 
free circulation of air increases the safety of the patient. It may also 
be selected whenever a large number of persons are to be rapidly anes- 
thetized, so that the surgeon may pass on to others and save a majority 
of lives, even if the drug endangers a few, as on the battlefield, where 
only a small bulk of anaesthetic can be carried. 

(3) Its employment is indicated in cases of Bright' s disease requiring 
the surgeon's attention, owing to the fact that anaesthesia may be obtained 
with so little chloroform that the kidneys are not irritated, whereas ether, 
because of the large quantity necessarily used, would irritate these 
organs. Quantity for quantity, ether is of course the less irritant of the 
two. 

(4) In cases of aneurism or pronounced atheroma of the blood-vessels, 
where the shock of an operation without anaesthesia would be a greater 
danger than the use of an anaesthetic, chloroform is to be employed, 
since the greater struggles caused by ether and the stimulating effect 
which it has on the circulation and blood-pressure might cause vascular 
rupture. 

(5) In children or adults who already have bronchitis, or who are 
known to bear ether badly — or, in other words, have an idiosyncrasy to 
that drug — chloroform may be employed. 

(6) Persons who struggle violently and who are robust and strong 
are in greater danger from the use of chloroform than the sickly and 
weak, probably because the struggles strain the heart and tend to dilate 
its walls. 

In operations upon the nose or throat chloroform is the best drug to 
employ, as by its use vomiting is avoided, only small quantities are 
needed to keep the patient under its influence, and the operator can 
readily examine the area of his operative procedures. Similarly, in 



238 SURGICAL PROCEDURES. 

some cases where vomiting following upon thoracic or abdominal opera- 
tions is greatly to be feared chloroform is to be preferred to ether. 

Because of its rapidity of action chloroform is largely used to the 
exclusion of ether during labor. 

From the time at which chloroform was first introduced into medicine as an 
anaesthetic until to-day it has been universally recognized that parturient women 
seem to possess an immunity to its poisonous properties ; and it is one of the curi- 
osities of medical literature that while the journals fairly teem with reports of 
chloroform deaths when the anaesthetic has been given for ordinary operations, 
death from this drug in parturient women is almost unknown. Various explana- 
tions have been put forward by obstetricians and . others as to the reason of this 
apparent immunity. 

Administration. 

We have already referred to the necessity of giving anaesthetics gently 
and in not too concentrated form. Ether is best given by means of one 
of two inhalers. 

The first is that of Allis, which is designed to give the patient plenty 
of air heavily laden with ether vapor. It consists of a wide collar- 
shaped piece of leather with a fenestrated metal lining, through the 
openings of which is passed from side to side a wide roller bandage. 
The ether is poured on these diaphragms, and the air passes over them, 
becoming heavily charged with the evaporating ether. 

A simple and readily-made inhaler for ether is made by shaping a 
towel, containing between its folds a stiff" piece of paper, into a cone or 
cornucopia, in the apex of which is placed some absorbent cotton or a 
small sponge. Upon this cotton is poured the ether, and the large open 
end of the cone is placed over the patient's face. If well made, this is 
a very satisfactory inhaler which can be hastily prepared for each case. 

Other ether-inhalers exist by the score, but nothing is gained by 
using them. 

Ether should be so freely given that the air is only present in about 
5 per cent, while the patient is struggling, thereby differing from chloro- 
form, which ought always to be given with about 95 per cent, of air. 

For the inhalation of chloroform the safest method of administration 
is by Lawrie's or Esmarch's inhaler, because these provide free circula- 
tion of air and do not distract the attention of the anaesthetizer from the 
respiratory movement by complicated apparatus. Apparatus much like 
these in allowing a free amount of air are the Hyderabad chloroform- 
inhaler or open-ended cone, with Krohne and Seseman's respiration- 
indicator attachment. 

The Junker inhaler, even with its modifications, is too complicated 
and cumbersome, and, while less chloroform is wasted in administering 
the drug, it must all be thrown out of the bottle afterward. If used at 
all, it should be used with the increased air-supply and respiration-indi- 
cator of Krohne and Seseman. 

A very useful addition to our methods of producing anaesthesia by- 
ether and chloroform is the administration of oxygen gas by inhalation 
with the anaesthetic vapor. By this means cyanosis is less likely to 
come on, accidents are more rare, and it is claimed that vomiting is 
often entirely avoided. It has been suggested that the mixture of oxy- 
gen with the vapor of these drugs may produce some chemical changes, 



ANAESTHESIA AND ANAESTHETICS. 



239 



but this view is incorrect. The mixture of ether vapor and oxygen 
simply forms a high explosive mixture. If ozonized ether is conducted 
into anhydrous ether, it forms a thick liquid which explodes if heated. 



Fig. 69. 



Fig. 70. 




Esniarch's 
sists of 



inhaler and chloroform bottle. The inhaler con- 
a wire frame covered by a thin piece of flannel. 



Krohne and Seseman's modi- 
fication of Lawrie's inhaler, 
with respiration-indicator at- 
tached. The inner lining is 
white felt, the outer case is 
leather. It can be used directly 
or by the air-pump attached to 
the top. 



It is probably ethyl peroxide. Chloroform when mixed with oxygen 
undergoes no change. 

If one of these inhalers is not employed, the chloroform is to be 
given by letting it fall drop by drop on a folded napkin held far enough 
away from the face to permit the inhalation of 95 per cent, of air with 5 
per cent, of chloroform vapor. This free supply of air is important, 
whether we believe death to be imminent from cardiac or respiratory 
failure ; but this supply of air matters little to the patient if he does 
not breathe freely, nor does the dose of chloroform amount to aught if 
it is not drawn into the chest. The dose of chloroform is not the 
amount on the inhaler, but the amount taken into the chest, and, finally, 
the amount absorbed by the blood-vessels. We agree so heartily with 
Lawrie's personal conclusions as to the manner in which chloroform is 
to be used that we print them below : 

1. Chloroform should be given on absorbent cotton stitched in an open cone or 
cap. 

2. To ensure regular breathing, the patient lying down, with everything loose 
about the neck, heart, and abdomen, should be made to blow into the cone held at 
a little distance from the face. The right distance throughout the inhalation is the 
nearest which does not cause struggling or choking or holding of the breath. 
Provided no choking or holding of the breath occurs, the cap should gradually be 
brought nearer to, and eventually may be held closer over the mouth and nose as 
insensibility deepens. 

3. The administrator's sole object while producing anaesthesia is to keep the 
breathing regular. As long as the breathing is regular and the patient is not com- 
pelled to gasp in chloroform at an abnormal rate, there is absolutely no danger 
whatever in pushing the anaesthetic till full anaesthesia is produced. 

4. Irregularity of the breathing is generally caused by insufficient air, which 
makes the patient struggle or choke, or hold his breath. There is little or no tend- 
ency to either of these untoward events if sufficient air is given with the chloro- 



240 



SURGICAL PROCEDURES. 



form. If they do occur, the cap must be removed and the patient must be allowed 
to take a breath of fresh air before the administration is proceeded with. 

5. Full anaesthesia is estimated by insensitiveness of the cornea : it is also 
indicated by stertorous breathing or by complete relaxation of the muscles. 
Directly the cornea becomes insensitive or the breathing becomes stertorous the 
inhalations should be stopped. The breathing may become stertorous while the 
cornea is still sensitive. The rule to stop the inhalation should, notwithstand- 
ing, be rigidly enforced, and it will be found that the cornea always becomes 
insensitive within a few seconds afterward. 

It is only necessary to add that the patient should be so dressed for 
an operation that his respiratory movements can be easily seen by the 
chloroformist. 

The use of chloroform requires that it shall be used only in the 
purest form, as medical literature shows that impure chloroform is very 
dangerous to life. Care should be taken that chloroform is not given in 
a room where there is a burning gas-jet unless there be good ventilation, 
as it is decomposed by the flame, setting free irritant fumes of chlorine, 
and thereby causing respiratory inflammation. 

Accidents from Anaesthetics. 

There still remain to be considered the methods which we are to 
resort to in accidents under anaesthetics. First, let us discuss the treat- 
ment of arrested respiration. This should be treated by the use of the 




Cut showing how proper traction on the tongue pulls on the epiglottis. 



ANESTHESIA AND ANESTHETICS. 



241 



Sylvester method, as by this means a greater amount of air enters the 
chest than by any other. For the free entrance of air we must so place 
the head that the epiglottis and tongue will not obstruct breathing. 

As long ago as 1889, Howard of London published a very interesting paper on 
this topic, which has since been widely quoted. While recognizing the value of 
his studies, a series of studies made by Martin and the writer have led us to reach 
somewhat different conclusions in regard to the posture of the head and its 
influence on the patulousness of the windpipe. Howard's statements in regard to 
the r61e of the epiglottis in cases of arrested respiration in anaesthesia are as 
follows : 

1. The epiglottis falls backward in apncea and closes the glottis ; therefore the 
first thing in order and importance is the elevation of the epiglottis. 

2. Traction upon the tongue, however, whatever the force employed, does not 
and cannot raise the epiglottis, as supposed. 

3. The epiglottis can only be raised by the extension of the head and neck. 




Cut showing how dragging the tongue over the teeth fails to pull on the epiglottis. 



Often in cases of circulatory failure during anaesthesia complete inversion of 
the patient may be practised with good effect, as seen in the accompanying cuts, 
taken from photographs of Dr. Kelly's method (Figs. 73 and 74). 

For the cardiac failure which comes on in cases of anaesthesia the 
best drug we can employ hypodermically is strychnine in full doses, at 
least ^ grain, repeated in ten minutes if need be, and associated with 
Y^ T grain of atropine sulphate, since it has been proved that strychnine 
is the best physiological stimulant to respiration and the heart that we 

16 



242 



SURGICAL PROCEDURES. 



have, while the atropine aids its influence on these functions and stimu- 
lates the vasomotor system. 

When an accident occurs under chloroform, this medication is par- 
ticularly necessary, for, as already pointed out, the influence of chloro- 
form on the blood-vessels is its primary and dominant effect. 



Fig. 




Showing the inversion of the patient as adopted by Kelly, and the method of performing artificial 

respiration simultaneously. 

This influence the author believes to be very much more worthy of attention 
than is generally recognized. Every physiologist knows that the action of the 
heart and respiration is greatly influenced by vasomotor relaxation. The gasping 
respiration of sudden faintness is probably due more to sudden vascular dilatation 
than to direct failure of the heart, and the exceedingly rapid pulse of shock is seen 
in conjunction with the relaxed blood-vessels so characteristic of this state. The 
integrity of the vasomotor system is as necessary to life as the integrity of the 
heart, since it is under the government of this system that the cardiac mechanism 
is active and the vital interchanges take place throughout the body. Acting upon 
this belief, the writer has found, both in the laboratory and at the bedside, that 
atropine enables more chloroform to be given without circulatory depression than 
can be used if no atropine is administered, and there is good reason to believe that 
the use of atropine by surgeons for the purpose of stimulating the respiratory 
functions or preventing cardiac inhibition by irritation of the vagus in reality 
prevents dangerous symptoms, chiefly by its vasomotor influence. 

Of the methods of artificial respiration, Sylvester's is by far the best, 
as it drives more air into the chest, or, in cases where this cannot be done, 



ANAESTHESIA AND ANESTHETICS. 



243 



we should not forget the very remarkable results to be obtained by prac- 
tising Laborde's method of rhythmical traction on the tongue. The tip 



Fig. 74. 




Same as Fig. 73. 



of the tongue being grasped, it is drawn out of the month regularly 
sixteen times a minute, and, probably by reflexly stimulating the respi- 
ratory centre, renews respiratory movements in apparently hopeless cases. 

Local Anesthesia. 

The production of local anaesthesia is sought for either through the 
influence of cold, which benumbs the nerve-endings or trunks, or by the 
use of cocaine or carbolic acid, which paralyzes peripheral sensory nerves 
when it is brought in contact with them. 

The advantages of local anassthema in minor operations are manifest. 
When cold is used, we can employ a small piece of ice dipped in salt, or 
a spray of chloride of ethyl or chloride of methyl or rhigolene. The 
chlorides of ethyl and methyl as commonly employed are contained in 
glass bulbs the ends of which taper to a point. This point having been 
broken off, the heat of the hand forces a fine spray of the liquid out of 
the glass, which as it strikes the skin becomes volatilized and simul- 
taneously freezes the surface. The skin becomes blanched, then shriv- 
elled and hard to the touch. After the anaesthesia, which lasts for a 



244 SURGICAL PROCEDURES. 

few moments, is over, the part becomes pink and remains congested in 
appearance for some hours. Rhigolene or ether may be used in an ordi- 
nary fine atomizer. 

Aside from cold, we most commonly use cocaine for local anaesthetic 
effects. As this drug cannot penetrate the skin, it can be applied only 
to mucous membranes, unless Ave introduce it under the skin by means 
of a hypodermic needle. The strength of solution of cocaine for 
mucous membranes varies with the membrane to which it is to be 
applied. Thus in the eye a 2 per cent, solution is often strong enough. 
In the nose from 2 to 4 per cent, solutions may be used, whereas for the 
proper ansesthetization of such dense membranes as are found in the 
vagina and rectum 10 per cent, solutions may be needed. The applica- 
tion of cocaine to the ocular, vaginal, and rectal mucous membranes is 
almost never followed by untoward symptoms, but when applied to the 
nasal or urethral mucous membrane it may be rapidly absorbed and 
produce profound collapse. The application of cocaine to the urethral 
mucous membrane is peculiarly dangerous, sudden death having followed 
its use in this area. Very weak solutions should be employed in small 
amounts in the urethra for this reason. 

When anaesthesia of parts protected by the skin is to be obtained, 
the drug in 4 per cent, solution may be injected under the skin very 
gently. Schleich has lately introduced a method of using a solution of 
2 parts cocaine muriate, \ part morphia muriate, 2 parts sodium chloride, 
in 1000 parts of sterilized water, which is deposited iii many beads or 
separate drops, the tissues being infiltrated or disteiided with the fluid. 
By using a sufficient quantity of the solution (even a weaker one being 
useful) extensive operations can be done without pain and without 
danger. A still later and more satisfactory formula, in which beta- 
eucaine is substituted for cocaine, is the following: Beta-eucaine 0.1, 
sodium chloride 0.8, distilled water 100. The use of beta-eucaine is 
free from many of the unpleasant constitutional sequela? often noted 
with cocaine. 

Local anaesthesia of the skin for minor operations may be obtained 
by drawing a camel-hair pencil wet vnth carbolic acid over the line in 
which the incision is to be made. 



CHAPTER XX. 

SURGICAL DIAGNOSIS. 
By Chauxcey P. Smith, M. D. 



It is well for the student to make a systematic, thorough, and method- 
ical examination of ever}' patient. He will have a knowledge of that 
case which will give him a better insight into its treatment, while he 
will gradually learn what is normal, and hence speak with some weight 
on what is abnormal or diseased. He will thus become familiar with 
joints, chests, malformations, diatheses, and many diseased conditions 
foreign to that one for which the patient comes. It will train him for 
close observation, and, furthermore, many times enable him to bring 
into play preventive medicine — /. e. the treatment of the future. 

Much may be learned of the patient — his habits, his strength, mal- 
formations, diseases, etc. — from inspection. To be thorough, one notes 
the expression, whether of pain, apathy, or paralysis, and one may often 
judge of the patient's occupation and general condition. 

External Examination. — When the patient is seen, observe his 
general appearance, whether robust or feeble. Note the color of the 
face — e. g. the florid face of plethora, the green of chlorosis, the pale- 
ness from anaemia, whether constitutional or due to hemorrhage, the 
sallow or yellow hue seen in septicaemia and hepatic disorders, the waxy 
skin of Bright's, the cyanosis due to obstructive respiratory or circula- 
tory disease, the crimson flush of pneumonia and erysipelas. The color 
of the conjunctiva is as important — c. g. the paleness seen in anaemia, 
the yellow of jaundice, the watery eye of the alcoholic, the glassy eye of 
cachexia. It should be observed particularly for hemorrhage when there 
is a history of injury, which, if subconjunctival, denotes serious intra- 
cranial mischief. In females note the presence or absence of chloasma, 
which occurs in pregnancy and during the menstrual periods. 

The Bye. — General protuberance, or exophthalmos, is seen in tumor* 
involving the antrum and brain. If this symptom be coupled with 
enlargement of the thyroid and irregular heart, the diagnosis of Base- 
dow's disease is simple. Conjugate deviation is seen in apoplexy. The 
pupil is contracted to a pin-point in opium-poisoning ; inequality is 
observed in brain-tumors, fracture of the skull, or some interference 
with the sympathetic nerve, such as carotid aneurism. A bright eye is 
seen in fever, coma-vigil in the typhoid state ; the presence of the arcus 
senilis denotes arterio-capillary fibrosis. Puffiness is seen about the eye- 
lids in inflammations near by, in nephritis, and in chronic alcoholics. 

The Head and Face. — Baldness, usually partial, of the eyebrows, 
moustache, or hair is common in lues. It is also seen at the back 

245 



246 SURGICAL PROCEDURES. 

of the head and in rickets, due to restlessness. Sears about the face 
denote some previous injury or disease. Their presence is important 
in epilepsy : if about the angle of jaw, tuberculosis is usually the cause; 
if on the lip, syphilis, although the primary lesion of lues may be found 
at the ala? of the nose and inside the mouth, particularly on the tonsd 
and soft palate ; if suspected, examine the contiguous lymphatic nodes. 
Sweating is a symptom in pyaemia, in rickety children — particularly at 
night — and in uraemia. In the latter the sweat has a urinous odor. The 
real age may be judged by the face, as well as the apparent age. By 
this is meant the real age from the life led, whether of overwork, anx- 
iety, or dissipation. Observe the general contour of the head and face, 
the symmetry or asymmetry. Myxoedema gives a moon-face ; acromeg- 
aly, prognathism of the lower jaw with overgrowth of the superciliary 
ridges. Rickets causes a box-shaped head. A general bulging of the 
face is seen in neoplasms of the antrum and unilateral swelling in infec- 
tive processes of the jaw. 

The Neck. — Enlargement of the lymphatic nodes of the neck is of great 
assistance in diagnosis. Bilateral enlargements are found in lues, the 
nodes being small, hard, shot-like, and movable ; in tuberculosis, either 
of the nodes themselves or secondary to a similar process in the lung ; 
they are usually large, adherent, often fluctuating or soft, and increase 
progressively in size as one approaches the primary lesion ; as, for 
instance, if due to infection through the tonsil, the largest node lies 
near the angle of the jaw, while from that point each node decreases in 
size until the supraclavicular lymphatics may be noted only with dif- 
ficulty. Bilateral enlargement is seen in Hodgkin's disease, the nodes 
standing out in great bunches and the enlargement continuing into the 
axilla. 

Unilateral enlargement is secondary to infective processes of the jaw, 
to faulty dentition, to malignant growth of tonsils, tongue, salivary 
glands, lips, or to tuberculosis. Occasionally it is seen in carcinoma of 
the breast and pylorus. The mouth should be examined as to the state 
of the tongue, the presence or absence of malignant disease or chancres ; 
the gingival border, for the blue line of lead- or green line of copper- 
poisoning. The state of the teeth is of importance, particularly in lym- 
phatic enlargement of the neck, in alveolar abscess, and as a possible 
source of infection in meningitis and antral abscess. Sordes are seen 
upon the teeth in low fevers. The breath has a sweet odor in pvsemia, 
a penetrating putrid odor in gangrene of lung, and a characteristic foul 
smell in epithelioma of the tongue or tonsil. Erysipelas usually starts 
from the angles of the mouth or eyes or alse of the nose and spreads 
therefrom. It rarely crosses the middle line. 

Tumors of the thyroid body rise and fall with deglutition. Thev may 
be unilateral or bilateral, fusiform or globular, and are common in 
women : the growth is often coincident with pregnancy, and can readily 
be distinguished from aneurism of the carotid by the foregoing symp- 
tom and by pressure-effects in the latter, and by the fact that aneurisms 
follow the line of the great vessels. 

The ear should be examined for the presence or absence of a dis- 
charge, whether of pus, denoting middle-ear and possibly mastoid dis- 
ease, or of blood, which with history of injury points to fracture of the 



SURGICAL DIAGNOSIS. 247 

skull, in which case the blood is soon replaced by a serous discharge of* 
cerebro-spinal fluid. 

Expansile pulsation is seen often in the suprasternal notch in aneur- 
ism of aorta. 

Upper Extremity. — The general contour of the shoulder should be 
observed, particularly where there is a history of injury. Too much 
stress cannot be laid upon the importance of observing not only the 
injured but also the sound shoulder. Great stress is laid upon this 
point, which it is necessary to follow not only about the shoulder, but 
also at the elbow, the wrist, the hip, or the ankle. In other words, 
compare the injured with the sound part : by doing this not only may 
the pathological condition be discovered, but also often much time and 
expense may be saved in court. 

One general proposition should be laid down which not only covers the upper 
extremity, but also the lower, and takes in every joint of the body ; and that is, 
any swelling in or about a joint which follows the general contour of the joint is 
due to some lesion within it. Whether this lesion be diagnosed as due to blood, 
pus, or serum depends entirely upon the skill of the observer. And, on the other 
hand, any fusiform swelling about a joint when the demarcation of the capsule 
which marks the limit of the normal joint cannot be made out is due either to 
effusion, which may be purulent, or to malignant growth. 

Dropping of the shoulder is seen in fracture of the clavicle, ; marked 
prominence of the acromion in subglenoid dislocation. The fusiform 
swelling which follows the foregoing rule is limited by the capsular lig- 
ament in joint diseases, which must be differentiated from the more fusi- 
form and less well-defined swelling due to sarcoma. 

Flatness of the shoulder is seen in atrophy of the deltoid muscle, 
which may be caused by injury or disease of the circumflex nerve, and 
in fracture of the humerus. If, following injury, a large swelling, fill- 
ing the axillary fossa, which may or may not have expansile pulsation, 
appear, with absence of the radial pulse, it would indicate traumatic 
aneurism of the subclavian or axillary artery. 

In elderly people pulsation is often observed at the inner side of the 
elbow, and is due to arterio-venous aneurism of the brachial artery and 
cephalic veins. It usually results from careless bleeding. 

The arm is swollen and (edematous in infective processes ; e. g. if the 
hand be involved in a cellulitis or a malignant oedema. This swelling 
is accompanied by a brawny feeling and by constitutional symptoms, 
which are absent when it is secondary to incomplete extirpation of the 
mammary gland and lymphatic nodes. In this latter condition the 
marble-like oedema is due to obstruction to the venous return caused by 
the scar. 

The axillary lymphatics are enlarged in carcinoma and infective pro- 
cesses in the mammary gland, in inflammation of the hand or arm in 
tuberculosis of the lymphatic nodes of neck, in lues, and occasionally 
in irritation of the female breast. The epitrochlear node is enlarged in 
infections of the hand and in syphilis. Great importance is put upon 
its enlargement in the diagnosis of the latter condition. 

The Elbow-joint. — When the elbow is extended the inner condyle, 
olecranon, and external condyle will be on the same transverse line. 
This is very important, as when there is any dislocation these three 
bony points will be out of line, while, on the other hand, in a fracture 



248 SURGICAL PROCEDURES. 

which does not involve the joint they will still remain in their normal 
position. Inspect the forearm for atrophy of muscle-groups which may 
be due to injury or disease of their respective nerves. Local enlarge- 
ments of the bones of the forearm are common : those with a tender, 
brawny surface are seen in inflammations, either subcutaneous, subperi- 
osteal,' or of the osseous tissue itself. Toward the distal extremity, par- 
ticularly if there be a history of injury, look for the silver-fork deform- 
ity of Colles' fracture and for the shorter and more abrupt deformity 
seen in a backward dislocation of the carpus. .Severe infections of the 
hand are accompanied by brownish-red streaks running up the arm to 
the lymphatic nodes — /. e. lymphangitis — or else by the purple lines of 
phlebitis. 

Much may be learned as regards the general condition of the patient from the 
hands, as the claw-hands of pseudo-muscular atrophy, the general flexion of fin- 
gers and hand seen in severe palmar or digital inflammations, the general over- 
growth of fingers of acromegaly, the spade-like hand of myxoedema, the clubbed 
fingers of phthisis, the cyanosis seen under the nails, indicating poor circulation, 
and hence often observed in conjunction with the clubbed fingers of phthisis, or 
the small round ulcers or scars occurring on the tips of the fingers observed in 
Keynaud's disease. A small fusiform, semi-fluctuating swelling in the line of a 
metacarpal bone or phalanx is suggestive of spina ventosa. The fingers of gout 
and of rheumatoid arthritis are excellent indices of the patient's condition. Wast- 
ing of the interosseous muscles is seen in progressive muscular atrophy and in 
leprosy. Athetosis due to intracranial lesions, or glassy skin, with absence of 
hair, seen after nerve-section, should not escape observation. 

The Chest. — Observe the shape: in emphysema it is barrel-shaped; 
in rickets the sternum is pushed forward (the so-called pigeon breast) 
and is associated with that enlargement of the costal cartilages known 
as the " rickety rosary." A long, flat, narrow chest indicates a tendency 
to tuberculosis of the lung. 

Unilateral enlaee/cment is found in pleural effusion, whether of pus, 
blood, or serum. The fifth interspace to the left may bulge, and is the 
favorite pointing-place for a purulent pleurisy. Protrusion of the sternum 
is a common symptom of aortic aneurism and mediastinal tumors, while 
in these conditions there is a prominence of the cutaneous veins of the 
chest due to deep obstruction. The scapula is prominent in lateral cur- 
vature of the spine, whether the scoliosis be primary in the vertebral 
column or secondary to unequal lengths of the legs. In fracture of the 
clavicle the winged scapula is common, as the fracture itself allows the 
shoulder to drop forward. The accessory muscle* of respiration are 
brought into play when there is obstruction to respiration, whether the 
obstruction be in the larynx as a foreign body or a membrane, or 
whether in the lung itself, as in fat-embolism. " Cheyne-Stobs respira- 
tion is met with in fatty degeneration of the heart, tubercular menin- 
gitis, uraemia, and apoplexy. Unilateral immobilization is significant of 
pneumonia, pleurisy, and fractured rib. 

The Breast.— Observe the general contour, the condition of the 
nipple and its areola. It is enlarged in lactation, sarcoma, chondroma, 
and abscess; its size is decreased after the menopause and in atropine 
scirrhus. The presence of chloasma denotes pregnancv or uterine dis- 
orders. The nipple is only retracted in carcinoma. ' Oftentimes the 
areola may have a baeony, waxy, or lardaceous appearance — Paget's 



SURGICAL DIAGNOSIS. 249 

disease — which precedes mammary cancer from one to three years. The 
breast has a general protuberance in sarcoma and retromammary abscess. 
Primary syphilitic lesions are not infrequent about the nipple, due to an 
infected nursing child. Oftentimes from the nipple, in women who have 
passed the menopause, a thick, purulent-looking fluid can bo squeezed : 
it may be mistaken for pus, but its true nature, which is modified secre- 
tion, may be diagnosed by the microscope. 

Carcinoma, the most frequent malignant mammary neoplasm, is 
usually situated to one side of the nipple. The tumor is the size of a 
walnut, is hard, adherent to surrounding structures, hence not sharply 
defined, and the overlying skin is coarse and has been likened to pig- 
skin. The nipple may or 'may not be retracted. The axillary lymph- 
nodes are enlarged. Sarcoma invades the whole breast, which is much 
increased in size, presents no distinct border, and is of unequal consist- 
ence ; overlying veins are prominent ; there is no axillary involvement 
unless ulceration has commenced. 

In retromammary abscess the whole breast is protruded ; there are 
axillary involvement and associated symptoms of inflammation. 
Occasionally a small hard tumor is found with associated axillary 
involvement in a middle-aged woman, which may be mistaken for 
carcinoma. It is a retention-cyst, and may be distinguished by its depth 
in the gland, its lack of infiltration and of skin-changes. 

For the recognition of any tumor of the breast the palm of the hand should be 
used. Any one, if he feels with his fingers, can find a tumor in a normal breast, 
which is simply mammary-gland tissue. If the palm of the hand be taken, the 
mammary gland spreads itself out against the ribs, but any tumor by means of this 
procedure will readily be distinguished. In examining for adhesions the arm 
should be abducted to make the great pectoral muscle tense; if the muscle is 
relaxed, false diagnosis is easy. 

If an ulcerating breast present for diagnosis, attention should be given to the 
character of the secretion: blood is common in sarcoma; a thin, sanious watery 
secretion and occasionally scabs are seen in carcinoma. Small blue circumscribed 
spots upon the anterior surface of the chest — taches bleuatres — are caused by 
pediculi either of the pubes or axilla. 

Abdomen. — From the general appearance of the abdomen much 
may be learned. Rigidity and oftentimes rigid retraction are seen in 
dyspnoea when the respiratory muscles, particularly those of the belly, 
are brought into play. Rigidity of the right side, particularly of the 
rectus muscle, is seen in peritonitis or appendicitis. The manner of 
observing this should be as follows : With the thumbs of both hands 
pressure should be made upon each rectus, beginning at the symphvsis 
pubis and following the line of Poupart's ligament. Starting again 
from the symphysis pubis, both recti muscles should be palpated up to 
and beyond the umbilicus. In examination of the belly the hand should 
be warm, as a cold hand will often cause, particularly in women, a 
momentary contraction of the muscles which may mask any diseased 
condition beneath. Observe whether the patient or the belly itself 
shrink at the approach of the examining hand. This is of value, par- 
ticularly in deep-seated pain. Often the stomach may be partly out- 
lined, particularly in thin subjects, and its size may be noted, as, for 
instance, an increase due to pyloric obstruction. A sausage-shaped 



250 SURQrCAL PROCEDURES. 

tumor in the right inguinal region, chiefly seen in infants, is due to 
intussusception of the bowel. 

The general contour of the belly should be observed. The pouting of the navel 
in anasarca, the lack of this in ovarian tumors, the ball-shape of ascites, the 
general distention of the peritoneal cavity observed not only in the foregoing 
disease, but also in cancer of the peritoneum itself or of the colon or liver otten 
a symptom of hydatid cyst— these are all of importance. Marbling of the belly, 
due to obstruction of the venous flow, is seen in pregnancy, liver diseases, ascites, 
and tumors pressing on the deep veins. 

Enlargement of the spleen, which can be easily distinguished, may be 
due to malignant disease, to leukaemia, or to malaria. In local enlarge- 
ments between the costal borders and below the xiphoid cartilage, if 
hard, cancer of the stomach, usually pyloric, is thought of, but when 
soft, pulsating, and expansile, they are caused by aneurism. General 
protuberance of the bowels is often a most characteristic symptom of 
tumors of the kidney, which push the bowel forward ; hence one should 
not be deceived by tympany on percussion. Tumors of the right hypo- 
chondrium, are usually of the liver and gall-bladder ; of the left hypo- 
chondrium of the spleen or a distended stomach ; renal tumors may be 
found on either side. In the right iliac region tumors may be caused 
by disease of the csecum and appendix, by pelvic abscesses, fecal 
accumulations, or cysts of the ovary and broad ligament ; in the left 
iliac, by tumors and cysts of the ovary, pelvic abscess, or volvulus. In 
the umbilical region we may find tuberculosis of the mesentery, and 
tumors may present themselves here which spring from other regions. 
In the hypogastric region the most common tumors are pregnant uteri, 
distended bladders, and fibroids. Lumbar tumors spring from the 
kidneys, or are cysts, perinephritic abscesses, or occasionally perityph- 
litic abscesses. 

When peristaltic motion is observed from without it is often due 
to obstruction of the bowels. Board-like rigidity with distention is 
seen in tubercular peritonitis. 

One may meet with the pelvic enlargement of ovarian tumors, the general 
bloating or distention of peritonitis and intestinal obstruction ; the doughy, 
brawny swelling, spreading from the pubis, of extravasated urine ; scars along the 
side indicate previous pregnancies or the results of great abdominal distention. 
Occasionally one sees, particularly at the navel, a persistent omphalo-mesenteric 
duct which may discharge a purulent material or even intestinal contents. A dis- 
charge at this point may be from a persistent urachus. In these latter conditions 
there will be more or less excoriation around the umbilicus. 

Observe the middle line particularly for old scars of previous operations, for 
hernia at the umbilicus, or separated recti muscles, and particularly, in the 
inguinal region, the condition of the inguinal rings. Pulsating swellings may be 
observed which if in the longitudinal axis of the body might indicate aortic 
aneurism, although aneurisms of the superior mesenteric artery are not infrequent. 
A flask-shaped tumor arising in the middle line from the pelvis, which often may 
reach the umbilicus or even beyond, and which fluctuates and is elastic, is prob- 
ably a distended bladder, which may be mistaken for a more serious condition. A 
tumor in either flank about the size of one's fist, which possibly can be grasped by 
the hand, with the history of movement, change in position, sharp colicky pain, 
and a lessened secretion of urine, usually indicates a floating kidney. This is 
particularly true of the right side. An elastic, flask -shaped tumor of the right 
hypochondrium may be a dilated gall-bladder or a hydatid cyst. Swellings in the 
ileo-costal space almost always originate from the kidney or surrounding structures. 
For instance, a dense, brawny infiltration on one side, with other characteristic 



SURGICAL DIAGNOSIS. 251 

indications of pus, would show the presence of perinephritic abscess, in which 
fluctuation is rarely detected. The diagnosis is made upon its pitting, the indura- 
tion, and the history. Tumors here with unchanged skin, particularly in the 
young, almost always spring from the kidney proper, and, if in the very young, 
of rapid growth, and of large size, with the other associated symptoms, are chiefly 
due to sarcoma, although cysts are not infrequent. 

The spine should be examined for any local enlargement, beginning 
at the atlas and going down to the coccyx ; as to its general contour, 
whether there be kyphosis, lordosis, or scoliosis ; and as to its mobility, 
as shown by movement. An undue rigidity of the spine is brought out 
by asking the patient to pick up an object on the floor. The influence 
of extension in the correction of deformity should be tried in all curva- 
tures, and in lateral curvatures measurements should be made of the 
legs for inequality. Cold abscesses lie always to one side of the spine 
and below the affected region. 

In the very young certain tumors present themselves, particularly around the 
sacrum, the lumbar region, and the coccyx, which are placed centrally, which are 
deeply connected, may or may not fluctuate, are oftentimes transparent and usually 
congenital ; as, for instance, spina bifida and the sacro-coccygeal tumors and der- 
moids. In many patients at the lower portion of the sacrum a small sinus, one to 
two millimetres in diameter, is found, with an intermittent discharge of unpleasant 
odor — called the pilo-nidal sinus — which, while congenital, yet often does not begin 
to be annoying until early manhood. 

In the inguinal region many tumors present themselves for diag- 
nosis, and this is a common seat for error. 

A hernial protrusion, whether direct or indirect, of the inguinal 
variety always presents itself in this region, and the diagnosis should be 
easy by its reducibility or the presence of the characteristic impulse on 
coughing. A hernia may be confused with the shot-like nodes of 
syphilis, which are always bilateral, and with the large immovable 
swellings of Hodgkin's disease or, if unilateral, with bubo from infec- 
tion from the foot or from the urethra, whether the latter be gonorrhceal 
or chancroidal. The nodes also enlarge in tuberculosis, epithelioma of 
penis or leg, etc. 

The Genito-ubinaey Teact. — Kidney. — Constant pain in this 
region may be due to cancer or to tuberculosis ; paroxysmal pain, to 
stone and foreign bodies. A tearing pain is felt in hydronephrosis and 
pyelitis ; a dragging pain which at times is paroxysmal, attended by 
nausea, is characteristic of floating kidney. Tumors of the kidney are 
not affected by respiration. In perinephritis the patient lies on his back 
turned toward the affected side, with his legs flexed. It simulates, on 
the right side, appendicitis. Sudden increase in the amount of urine 
passed, following suppressed urination, is pathognomonic of hydrone- 
phrosis. 

The penis should be observed for the presence or absence of scars — 
for discharges, which are very important, particularly when associated 
with a painful knee-joint. In elderly people, particularly after fifty- 
five years of age, a muco-purulent discharge, commonly seen a short 
time after defecation, is complained of, which they attribute to former 
disease, but which is simply due to enlarged prostate. The normal pros- 
tatic discharge is squeezed out by the act of defecation. The presence 
of a pin-point meatus or adherent foreskin in children may give valu- 
able aid in many conditions. 



2o2 SURGICAL PROCEDURES. 

Testicles. — In any abdominal tumor in the male the presence of the 
testicles should be sought for, as a retained testis is very liable to undergo 
sarcomatous change. The absence of one or both is important, particu- 
larly in painful swellings in the groin or about the rings. A nodular 
tumor of the epididymis in conjunction with a thickened vas is charac- 
teristic of tuberculosis. The testicle is uniformly large in sarcoma and 
luetic affections. 

The scrotum is always large, pear-shaped, and fluctuates (or if the 
tunica albuginea be greatly distended an elastic feel may be substituted 
for the fluctuation) in cases of hydrocele and hematocele. A worm-like 
condition of the left side of the scrotum which subsides in the recum- 
bent posture, and which may be prevented from recurring when the 
patient is standing by pressure upon the external ring, is due to vari- 
cocele. This is chiefly seen on the left side. 

Perineum. — The drawers of the patient should be examined in every 
case when pain is complained of in this region for the presence of pus 
and blood, which oftentimes are significant, though not noticed by 
the patient. If present, gonorrhoea, anal fissure, hemorrhoids, fistula 
in ano, and epithelioma may be the cause. Urinary fistulse are common 
in this region following stricture and urinary extravasation. A brawny, 
painful mass in the ischio-rectal fossa shows abscess. In this condition 
fluctuation cannot be detected. Hemorrhoidal tags denote past and 
possibly present hemorrhoids. 

The groin is the common seat of hernias, both inguinal and femoral, 
which are oftentimes difficult to differentiate. It may be said that if 
the finger be placed upon the spine of the pubis, any hernia which 
points externally to the finger is femoral — internal to it, inguinal. In 
fat people the spine of the pubis is found with difficulty, but may be 
easily reached if the leg be abducted and the finger run along the tendon 
of the abductor longus where it is inserted into this bony landmark. 
A large fluctuating swelling which may point above or below Poupart's 
ligament, externally or internally to the femoral vessels, or between the 
tuberosity of the ischium and the great trochanter, with a history of 
long duration, is possibly a cold abscess, and is very suggestive of spinal 
or hip-joint tuberculosis. 

Enlarged, iender lymph-nodes follow infected wounds of the foot, epithelioma 
and infection of the penis. They may also be enlarged from tuberculosis. 
With the history of an injury in elderly people when fracture of the femoral neck 
is suspected, resistance felt in Scarpa's triangle is very important as an aid in diag- 
nosis, particularly when there is flattening of the trochanter on the same side and 
a puckering above the patella, which latter is due to a shortening of the quadri- 
ceps extensor tendon. 

The Lower Extremity. — The knee is flexed and everted in tuber- 
culosis ; flexed and fixed in shortening of the hamstrings ; slightly flexed 
in every joint-effusion, as in this position the joint may be distended to 
a greater degree with less pain. In "joint-mice" and dislocation of 
the semilunar cartilages the knee is often flexed and locked. In hydrops 
articuli the joint is much swollen, but its contour is preserved and the 
lines of the capsular ligament are sharply defined. In all effusions in 
the knee-joint the patella is said to float, whether the effused fluid be 
blood, pus, or serum. Sinuses about the joint are commonly due to 



SURGICAL DIAGNOSIS. 253 

neighboring tuberculosis. They are small, often multiple, and present 
the usual granulations of this condition. All joints should be examined 
for muscle-spasm, which is characteristic of tuberculosis. 

The Leg. — The anterior surface and shin are favorite seats for the 
tertiary lesions of lues. Tenderness on percussion and old sears have 
great diagnostic significance as to a previous active process. Varicos- 
ities, chiefly seen in women, are due to venous obstruction, whether 
just above the knee, pelvic, or thoracic, and follow the course of the 
internal saphenous vein, and often are associated with an obstinate pig- 
mented ulcer on the shin. 

The Foot. — Pain felt in the arch, with no perceptible injury, maybe 
due to flat-foot. Distention of the ankle-joint, whose normal structure 
will not admit of much fluid, is seen in tuberculosis ; tenseness of the 
tendo Achilles in talipes equino-varus. 



The Diagnostic Significance of Pain. 

The writer is indebted to Dr. J. H. Musser for the following classifi- 
cation and paragraphs on Pain : 

Pain is primarily due to either functional or local causes, the func- 
tional being illustrated by the headaches of anaemia or the heel-pain of 
gout, while local causes may be due to hyperemia, inflammation, or 
injury. 

Pain is shown (1) by facial expression ; (2) by posture. It is often 
pathognomonic, as, e. g., the doubling up in cramps ; the bent knee of 
arthritis ; the retracted head of meningitis ; the straining attitude of 
dysuria ; the support of the arm in clavicular fracture ; flexion of the 
thighs in peritonitis ; the ape-like posture with general tremor seen dur- 
ing micturition with vesical calculus ; the sudden upright posture in 
angina pectoris ; the support of the head in cervical caries ; the eversion 
of the leg in fracture of the cervix femoris ; the rigidity of the injured 
side in fracture of rib ; the immobile side in pleurisy. (3) By reflex 
actions — as, e. g., stiffening of the belly-wall in peritoneal inflammations, 
especially upon palpation by examining hands ; the erections of urethral 
irritation and frequent urination of bladder disorders ; and the brassy 
cough of aortic aneurism. (4) By the associated phenomena of disease, 
injury, etc. 

According to Musser, pain should be studied for the following aspects : 
First, the mode of onset; second, duration; third, time of occurrence; 
fourth, character ; fifth, seat ; sixth, whether affected by heat, cold, pres- 
sure, posture, or rest. 

(1) Mode of onset oftentimes gives clue to morbid processes. 

Sudden onset points toward inflammations of serous membranes, as in perito- 
nitis ; or to obstruction of some normal mucous canal, as in appendicitis, obstruct- 
ing gall-stones, or vesical calculi ; or to rupture of an organ or part, as sudden pain 
in an aneurism or in perforation of the stomach and intestines : sudden pains are 
also observed in neuralgias, particularly in the branches of the fifth nerve. Slow 
pain usually betokens slow development, as, for instance, painful urination due to 
enlarged prostate. 

(2) Duration shows the acuteness or chronicity of the cause. 

Pain of long duration is always associated with a long-standing cause. It 



254 SURGICAL PROCEDURES. 

should be noted whether it is temporary or constant, as from this one may be able 
to judge of the disease : temporary pain may indicate either relief or a cessation 
of the disease, while constant pain points to a constant cause. As an example a 
temporary pain is felt in the passage of hard feces, yet constant pain during the 
passage points to some organic lesion of the rectum, as fissure or hemorrhoids. 
The duration may indicate the prognosis, as when in a strangulated hernia the 
pain ceases gangrene may have occurred. Pain following shock shows that reac- 
tion has set in, and hence is a favorable sign. " The abdominal surgeon should 
welcome its presence after operation" (Musser). 

Comtant pain is seen particularly in organic lesions, in inflammations 
of all the tissues, particularly those of bone. It may be reflex in cha- 
racter, as the pain and uneasiness felt in the right shoulder which is more 
or less constant from gall-stones. Paroxysmal pain is usually associated 
with nerve-lesions or neuralgias, and also with obstruction to some canal 
by a foreign body. Periodical pa ins are chiefly due to malaria or syph- 
ilis or to some atmospheric influence, or are in relation to some physio- 
logical process. 

The Time op Occubbence of Pain. — Nocturnal pains are com- 
mon in lues, in all inflammations of bones, as seen in the night-cries of 
children with hip-joint disease. 

Pains in the day are oftentimes due to the position of the patient, such as pain 
in the instep due to flat-foot. The time and the relation to some function are often 
very important. Gastric pain coming on before meals means gastralgia ; that 
occurring after meals is due to some organic lesion of the stomach, as cancer or 
ulcer, or at times to dyspepsia. A common example is the pain in cystitis which 
is felt before urination, and which is relieved by this act. This pain is due to the 
contact of the urine with the irritated and sensitive mucous membrane. Pain 
occurring during micturition points toward stone or inflammation of the urethra ; 
pain occurring after it often is due to stone, when the bladder contracts upon its 
rough surfaces. This pain is usually relieved as the urine accumulates and lifts 
the bladder-wall away from the calculus. 

The Chaeactee of Pain. — Pain may be spoken of as being due to 
.soreness, tenderness, aching, lancinating, or throbbing, and from each of 
these characteristics one is able to learn much of its cause. 

Soreness, particularly on movement, often indicates muscular or ligamentous 
origin. An aching pain is due to nerves or muscles. Aching pains may be gen- 
eral, and often usher in more serious general constitutional diseases, as the general 
pains in the bones preceding influenza. Throbbing pain is often an accompani- 
ment of acute inflammation, which, if it has been of several days' duration, points 
many times toward abscess-formation. Sharp and lancinating pain is seen in 
obstruction to canals by some foreign bodies, particularly calculus, and also in 
inflammation of serous membranes. A dull pain, particularly in bones, betokens 
a chronic, slow inflammation. Pain accompanied with tenesmus is usually asso- 
ciated with foreign bodies, as blood and stone, and is noted chiefly in the rectum 
and the bladder. 

The character of the pain often indicates the structure involved — as, e. g., itch- 
ing, burning pain in skin and mucous membranes, while the soreness which is 
increased on movement and pressure is characteristic of muscles. A deep-seated, 
boring pain is characteristic of bone-lesions. A sharp, lancinating pain points 
toward nerves. A dull, constant, aching pain is often associated with disease of 
some viscera. If the lightest contact to any part elicit pains, it points toward 
affections of the cutaneous nerves. If the skin can be freely handled without 
causing pain, this source can be eliminated. If deeper pressure on the groups of 
muscles be made and soreness be complained of, it points toward muscles. If, on 
making deep palpation over the location of a bone deep-seated pain is elicited, 
while the skin and muscles are free from pain, bone-lesions, chiefly of inflamma- 
tory nature, may be thought of. 



SURGICAL DIAGNOSIS. 255 

The location of pain may be said to point fairly accurately to the 
lesion, providing that the nerve-distribution is recalled ; but one should 
always remember the possibility of referred pain. Examples of this 
are very common and frequently overlooked, hence the disease is not 
treated. Mention is made here of some of the commonly referred pains 
which are apt to mislead. 

Pain over the right shoulder is associated with gall-stones by means of the vagus 
and the third or fourth cervical nerves. Pain back of the ear may be due to 
mastoid disease, particularly if there be tenderness over this region ; but the mouth 
should always be examined for carcinoma of the tongue. Knee-pains often mean 
hip-joint disease. Pain in angina pectoris radiates down both arms. In renal 
disease it follows Poupart's ligament or is felt in the bladder or the testis, or may 
radiate down the inner surface of the thighs. In vesical calculus pain is felt at 
the end of the penis. In diaphragmatic pleurisy it is located above the umbilicus 
and to the front. In Pott's disease anywhere in the spine it is always referred to 
the anterior surface of the body. The high cervical Pott's lesion will give pain in 
the throat, with irritation which is too commonly treated for a cold. In disease at 
the junction of the cervical and dorsal vertebras pain is referred to the intercostal 
nerves and their distribution, and is often called " intercostal neuralgia ;" mid- 
dorsal pain is referred about the belly, and in small children is frequently thought 
to be due to colic. In disease of the lumbar spine pain is referred down to the 
pelvis. 

Pain between the shoulders oftentimes is due to aneurism or to cancer of the 
oesophagus ; pain in the neck may be transmitted by the phrenic nerve and be due 
to pericarditis or diaphragmatic pleurisy. So-called sciatica is often caused by a 
fissure of the anus, by cancer of the rectum, or by ulcer, and may be cured by 
treating these conditions. The pain of hip-joint disease may not only be felt in 
the knee, but may extend to the heel. Never make a diagnosis of " rheumatic " 
and "growing pains" in a child without a thorough examination, looking par- 
ticularly for tubercular disease in some joint or joints. 

Pain Modified by Pressuee and Movement — Pain increased by 
pressure is due to inflammation ; if relieved it is either neurotic or func- 
tional. Pain that is relieved by pressure, particularly around the belly, 
often is due to a reposition of some organ which has been dislocated : 
this is chiefly seen in the kidney, as when a patient himself can replace 
a movable kidney and thus relieve the characteristic sickening pain of 
this affection. 

Pain that is increased by pressure at "nerve-points" means neuralgia. If by 
pressing upon the head or by having the patient jar himself by his feet pain be 
elicited along the spine, it is characteristic of Pott's disease. The influence of 
movement is very suggestive. The contraction of an inflamed muscle is painful. 
If it be found that certain active movements are painful, but that the movement 
can be made passively without causing pain, it may be put down as muscular. It 
is not the position of the limb which is painful, but the method of obtaining it. 
Ligamentous pain, whether active or passive, is elicited by any movement which 
stretches the ligament; hence in moving any joint, if it can be done passively to 
its normal degree without causing pain, the articular surface composing that joint 
may be said to be free from disease ; but the moment the joint and the ligaments 
about it are put upon the stretch and pain be elicited, it is ligamentous in origin. 

Pain in Special Regions. — Pain in the extremities, if bilateral, may 
may be due to disease of the spinal cord or to neuritis, toxaemia, or 
pressure ; if unilateral, to injury, inflammation, or pressure, or to 
transmitted sensations. 

Pain in the foot is usually caused by flat-foot; in the heel, by gouty or rheu- 
matic conditions, although it may be caused by aneurism of the popliteal artery 
pressing on the popliteal nerve. Pain in the space between the third and fourth 



256 SURGICAL PROCEDURES. 

metatarsal bones is due to pressure on a small branch of the plantar nerve, which 
is nipped between the articular ends of the two contiguous bones. Pain is usually- 
located in the shoulder when due to liver disease; in the back, when due to dis- 
orders of the stomach ; in the interscapular region, in ulcer of the stomach. Pain 
behind the sternum, common in gastric disorder, may also be due to aneurism, 
tumor, or angina pectoris. Pain in the sternum or ribs may be due to syphilis or 
periostitis. The pain in the loins, when acute, may be due to a dislocation of the 
kidney, to calculus, to uterine disorders ; when chronic, to uterine and renal dis- 
orders and varicocele. 

Coug-h. — In aneurism of the carotid, and even of the aortic arch, a 
peculiar metallic, brassy cough and irritation of the throat are com- 
plained of. The dry, constant, hacking cough due to irritation, which 
by turn is caused by pressure, is often seen in women with thyroidal 
enlargements and in many tumors of the neck. The constant cough 
of irritation due to enlarged uvula, and a cough similar to that described 
above as due to pressure of tumors, may be found associated with car- 
cinoma of the oesophagus. Cough may be also caused by the presence 
of a foreign body in the auditory meatus. It is transmitted along the 
auriculo-temporal branch of the fifth nerve. In infants cough may be 
due to irritation of the stump of a tooth. 



PART IV. 
INJURY AND REPAIR. 

CHAPTER XXI. 

WOUNDS. 

By Chas. B. Nancrede, M. D. 



Subcutaneous Injuries, Contusions, Lacerations, etc. 

Subcutaneous Injuries, Contusions, and Lacerations vary in 
severity from the pain and swelling of the skin, which promptly appear 
and as promptly disappear, for example, after a cut from a whip — i. e. a 
wheal — to complete disorganization of a limb, the skin alone remaining 
intact. The most common causes are blows from or falls upon blunt 
objects, the passage of wagon- or car-wheels, and entanglement of a 
limb in ropes or machine belting. The connective tissue with its vessels 
always suffers. When only a few vessels are ruptured an ecchymosis or 
bruise results, with pain, tenderness, swelling, and discoloration of the 
parts, the effused blood as it reaches the surface changing its purplish 
hue to a brownish, green, and yellow tint as it fades away. The effusion 
may either be evenly distributed throughout the damaged tissues — hem- 
orrhagic infiltration — or form circumscribed collections — ecchymoses or 
sugillations. In lax tissues, as the axilla, or where a limb has been 
traversed by a wagon-wheel, the major part of the skin may be stripped 
off from the deep fascia, and the cellular tissue and the intermuscular 
spaces be distended by such an enormous extravasation that death 
results from the sudden abstraction of blood from the circulation, or 
gangrene occurs because the pressure upon the small vessels is such that 
the collateral circulation cannot be set up. These accidents rarely occur 
except as a result of the giving way of a large vein — e. g. the axillary 
or external iliac. When the larger blood-collections become circum- 
scribed by condensation of the surrounding tissues, they are called hcema- 
tomata. Occurring in certain regions, a prefix or suffix is added to indi- 
cate the locality — -cephal when occupying the scalp (cephalhcematomata) ; 
arthrosis when a joint is concerned (hamiarthrosis). The pressure exerted 
by the effused blood usually arrests the bleeding, and coagulation gen- 
erally sooner or later occurs. The clot eventually breaks down into a 
thick, reddish fluid which often assumes a brighter tint when exposed to 
the air. Repair takes place without true inflammation unless infection 
occurs. The coloring matters of the disintegrated clot diffuse into the 

17 257 



258 INJURY AND REPAIR. 

surrounding tissues, and with the liquid portions are removed by the 
lymphatics. 

Symptoms. — Pain, except when a nerve-trunk is damaged, is de- 
pendent upon and proportioned to the tension resulting from the 
swelling, which varies with the amount of effusion and the laxity of the 
tissues : when confined beneath tense, unyielding structures, as fasciae, a 
small effusion may be productive of severe pain, while a large one in 
lax tissues, as the scrotum or eyelids, may cause nothing beyond slight 
discomfort. Discoloration shows promptly if the bruise is superficial, 
but may not appear for many days if the deeper parts are those injured 
or the effusion occurs beneath an unruptured fascia. At first of dark 
purple, the color changes to green, then to yellow, finally fading out. 
Constitutional reaction — "aseptic fever," so called — is proportioned to 
the extravasation and laceration ; i. e, the amount of fibrin-ferment 
and nucleins available for absorption. When the injury is super- 
ficial the overlying skin presents the evidences of plastic exudation — 
viz. normal reparative processes — -which soon disappears unless infection 
occurs. 

Treatment. — Rest must be secured for the part by splints, position, 
or both. Even where no appreciable lesion of the epithelium is dis- 
cernible, it is better to carefully sterilize the surface and employ subse- 
quently only aseptic applications, because portions of the skin may have 
been actually killed, and yet no evidence of this appear until later : 
these precautions are imperative if abrasions do exist, lest infection 
occur. Cold may be employed to check effusion by applying ice-bags, 
iced lotions, or aseptic lotions so disposed as to permit constant evapora- 
tion taking place, especially for the more superficial injuries. Alcohol- 
and-water is one of the best evaporating lotions, to which morphia may 
be added if desired. The value of lead-water is doubtful. Irrigation 
with cold sterilized water may sometimes prove useful in certain severe 
contusions, but all cases where any form of cold is used must be care- 
fully watched lest gangrene be precipitated. Massage has been recom- 
mended for slight contusions, because it favors rapid disappearance of 
the effused blood by distributing it over a greater area, but a judicious 
selection of cases must be made, lest more harm than good result. In 
the more severe injuries the effusion may be checked and absorption 
hastened by gentle, elastic pressure, such as can be secured by the careful 
application of bandages over many layers of cotton, first having aseptic- 
ally emptied all blebs and protected them by proper dressings. If the 
tension comprises the integrity of the parts, aseptic aspiration, followed 
by gentle pressure to prevent fresh hemorrhage, usually suffices, although 
incision may be requisite to satisfactorily evacuate large collections if 
much clot be present. When coldness and oedema of the part show that 
the collateral circulation is seriously interfered with by the pressure of 
the effused blood, as this probably comes from a large vessel or ves- 
sels, aseptic incision, ligature, perhaps packing and proper drainage are 
indicated. 

Injuries of Vessels. 

Arteries.— Mere contusion, if the vessel be superficial, compression 
against a bone if deeper, or overstretching during the production or 



WOUNDS. 259 

reduction of dislocations, may cause partial or complete rupture of an 
artery. In the former variety the internal or middle and internal coats 
yield, usually in such a manner that, curling upward and downward 
because of their normal elasticity, they partially or completely occlude 
the vessel, thrombosis soon rendering complete any partial blocking. 
Even when the incurved coats do not seriously interfere with the blood- 
current thrombosis often results. 

Symptoms. — Unless the incurved coats at once block the vessel, no 
symptoms appear until thrombosis diminishes or cuts off the blood- 
supply, when the pulse in the distal segment of the artery either becomes 
feeble or is arrested, according to the rapidity of clot-formation : the 
part becomes numb, powerless, pale, and cold, with neither swelling nor 
extravasation to explain the condition. Sometimes severe pain is com- 
plained of. Later, if gangrene does not occur, enlarged collateral 
vessels may be detected. When the rupture involves all the coats and 
the opening is large, if the surrounding tissues are lax, an enormous 
soft, fluctuating, imperfectly circumscribed swelling forms in a few 
moments, and the loss of blood from the circulation may be so great as 
to produce syncope. The distal portion of the limb becomes swollen, 
pale, and oedematous, and no pulsation can be detected in the vessels 
below the injury. Extreme .pain is common. Pulsation is absent in the 
swelling or can onlyTxTdetected over a small area : it is not expansile, 
nor is there usually bruit nor thrill. If a bruit be present, it is not 
conducted along the vessel. If the surrounding tissues are dense 
enough to resist the effusion, a small rent in even a large vessel may 
give rise, for a time only, to more or less vague symptoms of traumatic 
aneurism, and then, after some days, perhaps quite suddenly, the barrier 
yields and the blood spreads widely through the limb, forming a cha- 
racteristic arterial hcematoma. 

Diagnosis. — When immediately after injury a diffuse, fluctuating 
swelling, perhaps pulsating over a small area, with bruit and thrill, 
appears in the course of an artery, with cessation of the pulse below, 
the diagnosis is clear enough ; but when the vessel is deep-seated and 
much inflammation exists, the condition closely simulates acute phleg- 
mon or even a rapidly-growing sarcoma. If neither thrill, bruit, pul- 
sation, nor alteration in the distal pulse can be detected, exploration 
with a grooved needle or aspirator must precede any active interference 
in doubtful cases. Traumatic aneurism, arising from yielding of the 
partially ruptured arterial wall, appears some time after injury and 
presents the ordinary symptoms of aneurism. 

Treatment. — When that surgical rarity, simple occlusion, results 
from contusion of a large vessel, carefully sterilize the skin, dress with 
abundance of sterilized cotton, place the limb in an elevated position, 
and wait to see if gangrene ensue. The gangrene, if it occur, may prove 
to be less extensive than at first appeared probable, one or more toes 
perishing instead of the extremity, so that before operating it is better, 
if possible, under aseptic dressings, to allow the line of demarcation to 
form and not amputate at the level of arterial occlusion. Traumatic 
aneurism must be treated as indicated by the locality and calibre of the 
vessel. An arterial haematoma — i. e. a diffused traumatic aneurism — re- 
quires prompt intervention. As the condition is really a wounded artery, 



260 INJURY AND REPAIR. 

it should be treated as such if the vessel be of any size. In addition to 
the danger from mere loss of blood, the effusion often interferes so seri- 
ously with the collateral circulation that gangrene will occur unless the 
pressure be relieved. Gentle compression has been recommended when 
the extravasation tends to cease spreading and the collateral circulation 
is fair. This is questionable practice, except for the smaller arteries. 
When the diagnosis is clear, ligation should be done as directed for 
traumatic (circumscribed) aneurismT The efficiency of modern methods 
for controlling hemorrhage, the immunity conferred by asepsis against 
secondary hemorrhage and septic inflammation, and the certainty of 
remedying the effects of the injury, all indicate that this is the proper 
course to pursue. Moreover, the necessary incisions will permit of the 
removal of so much of the effused blood as will materially relieve the 
collateral circulation. While amputation at the level of the rupture is 
the only resource if gangrene of the segment of the limb actually occur, 
either before or after ligation, the emphatic warning must be repeated 
that with aseptic methods the surgeon can usually safely wait until no 
doubt exists as to the extent of the destructive process. 

Veins. — Contusion occasionally produces rupture of the internal 
coats, initiating a thrombosis which blocks the vein, but even when the 
main vein of a limb is concerned the free anastomosis prevents gangrene. 
The extent of extravasation in subcutaneous rupture of veins is rarely 
serious in itself, but if one of the main veins be ruptured or a branch 
be torn off close to the parent trunk, where the surrounding tissues are 
lax, as in the axilla, the amount withdrawn from the general circulation 
may threaten life or cause gangrene by interfering both with the direct 
and collateral circulation. 

Treatment. — Elevation of the part, coupled with cold and equable 
pressure, usually suffices, but where the effusion causes so much com- 
pression as to threaten gangrene incision and suture with catgut for 
small wounds and ligation for transverse wounds should be done, after 
turning out all the clots. While pressure combined with elevation is 
often sufficient, suture or ligation is perfectly safe, and more reliable 
when the effusion tends to spread. 

Lymphatics. — In all contusions lymph is extra vasated, and in 
some cases much of the effusion is composed of lymph. It may even 
form a fluctuating tumor containing yellowish or reddish fluid. These 
lymph-effusions most often result from laceration of the lymphatics tra- 
versing the subcutaneous cellular tissues, and are therefore most apt to 
occur when the skin is extensively displaced from the subjacent parts. 
These tumors form rapidly at the outset, to soon become stationary 
(lymph-cysts). When they progressively increase, rupture with the for- 
mation of a lymph-fistula may result. 

Injuries of Nerves. 

Experiment shows that slight blows inflicted upon nerves produce 
extravasations of blood into the neurilemma and between the nerve- 
fibres. The fibres are contracted at the point struck and irregularly 
enlarged above and below. In the more severe rases the Wallerian 
degeneration sets in within a few days, but where the hemorrhage is 



WOUNDS. 2(51 

very slight and only a few fibres are torn, the paralysis rapidly 
disappearing, most of the fibres undergo, according to Mitchell, 
only a mechanical disturbance, and a rcslihilio ail inliyraiii rapidly 
occurs. 

Symptoms. — These vary with the severity of the injury. In the 
slighter eases pa.in will be felt at the point of injury, immediately fol- 
lowed by niini/nirsH and fit rmiiuii ion in the peripheral distribution of the 
nerve. A sensation of burning or heat is often experienced, and even 
actual flushing of the skin has been occasionally observed. All these 
sensations usually disappear in a few minutes, but the tingling may per- 
sist for several days. In more severe eases the punestliesut and paresis 
continue, neuralgic pain appears, and a distinct chronic neuritis, tending 
to spread and resulting in various trophic lesions, occurs. After the 
most severe contusions immediate and complete paralysis of both motion 
and sensation ensues. This may pass away with great rapidity : 
improvement may not set in for weeks or months, or tin: paralysis may 
be permanent. 

Tt is well to note that the peripheral areas supplied by nerves may vary in 
different, individuals, and that anastomoses occur with other nerves: ignorance of 
these facts lias led, and again may lead, to the most erroneous conclusions. Com- 
plete rupture of a nerve is of course accompanied by initial pain and immediate 
sensory and motor paralysis in the area supplied by the severed nerve, the changes 
consequent upon nerve-section following later. 

Treatment. — When seen early an attempt should be made to limit 
the effusion of blood and the exudates of repair by perfect rest of the part: 
morphia is often demanded for the pain. Later, counter-irritation, 
blistering, massage, and galvanism are indicated. When a well-grounded 
suspicion exists that the nerve has been actually severed, and no 
improvement in the paralysis takes place in from eight to ten months — 
symptoms of neuritis being absent — an exploratory operation may be 
done, the nerve examined, and if found severed the ends must be fresh- 
ened and sutured together: if markedly reduced in size at the point of 
injury, in extreme eases, resection of the damaged portion and suture is 
indicated. If, despite of appropriate treatment addressed to the neuritis 1 
when this occurs, the disease continues to extend, Bowlby suggests that 
the nerve should be exposed and stretched to free it from adhesions to 
and pressure by the surrounding inflamed tissues : nutritional changes 
are also set up in the thickened nerve, tending to remove the compress- 
ing inflammatory exudate. 

Injuries of Muscles. 

Much pain, effusion of blood, and loss of power may result from 
contusion of muscles, but these symptoms are usually only temporary. 
Sometimes permanent <tfroj)hi/_ follows. This may perhaps be due to 
serious interference with or deprivation of arterial blood by the pressure 
of the hemorrhagic effusion producing an isc/ucmic para/i/sis, but more 
probably results from myositis, causing coagulation-necrosis, fatty degen- 
eration, and destruction of the muscular fibres. External violence may 
1 See Chapter XXXV III., and consult neurological treatises. 



262 INJURY AND REPAIR. 

rupture the sheath or a part or the whole of a muscle, or sever both 
muscle and sheath. 

Symptoms. — As just stated, contusion— i. e. more or less extensive 
laceration of a muscle— produces pain and loss of function lasting for a 
variable period, but complete division presents additional symptoms. 
Sudden, sharp pain is felt, followed by a dull aching and loss of power. 
The ends freely retract, and the interval can be felt to increase if 
attempts are made to contract the muscle. Much blood is effused 
between the ends of the muscle and into the surrounding tissues. In 
due time this is absorbed, and repair is effected by the formation of 
cicatricial tissue, unless the ends are too much separated, when atrophy 
usually results with loss of function. If but little separation has taken 
place, partial regeneration of the muscle-elements may occur, so that 
the scar is not wholly fibrous. Much of the original power is regained 
by the muscle, especially if only a small gap has to be filled by scar- 
tissue, but permanent airoph y or contracture may Jesuit. 

Treatment. — Mere contusion must be treated by placing the part 
in such a position as will relax the muscle, and this must be maintained 
by splints aud posture until healing occurs. If ruptured, two courses 
are open to the surgeon : The injury can be treated as just recommended 
for contusions, in addition maintaining quiet of the muscle by firm 
bandaging, which should be so applied as to approximate the separated 
ends and restrain further effusion of blood. Cold may also prove ser- 
viceable. When the restoration of the function of the injured muscle 
is of great importance, antiseptic incision and suturing should be done, 
care being exercised in passing the sutures to include, when possible, in 
some of the stitches the aponeurotic covering of the muscle, as other- 
wise the sutures too often cut out before union takes place. Even with 
considerable separation and a large scar the functional result is so often 
good that operation is seldom indicated. Electricity, massage, active 
and passive exercise will aid in restoring function. Secondary suturing 
where a large gap exists and the case is of some standing will usually 
fail. 

Hernia of a muscle, when following distinct traumatism, results 
from an unhealed rupture of a portion of the investing muscular 
aponeurosis. 

Tendons seldom suffer from contusions, but repeated injuries and 
strains sometimes lead to ossification, as in so-called rider's bone. Rup- 
tures, especially of the quadriceps femoris tendon, sometimes occur from 
glancing blows, as by the end of a wagon- tongue. 

Symptoms. — They are similar to those of division of a muscle— viz. 
pain, sudden loss of power, a gap between the extremities of the tendon, 
and effusion of blood. 

Treatment.— This should be by suture if the tendon belong to an 
important muscle and the separation be great. If this cannot be done 
or is deemed inadvisable, the same treatment as was recommended for a 
ruptured muscle must be adopted, remembering that diminution, not 
complete loss of power, is the worst that will follow the lengthening of 
the tendon. Secondary suture may be tried if palliative treatment gives 
a poor functional result. 



WOUNDS. 263 



Contusion of Bone. 

The blood may be poured out beneath the periosteum or into the can- 
cellous tissue, in the former position being usually only small in amount, 
except in children, in whom the periosteum is much more vascular and 
less firmly adherent to the bone than in adults. This is especially true 
of cephalhcematomata, where quite large accumulations form, which by 
subsequent changes closely simulate a depressed fracture because of par- 
tial ossification of the margin of the exudate. Absorption of the effused 
blood, after the manner already described, is the rule here as elsewhere, 
and suppuration is rare. 



CHAPTEE XXII. 

GUNSHOT WOUNDS. 

By Charles B. Nancrede. 



In civil life small shot, pistol-balls, and, more rarely, rifle-bullets are 
the vulnerating bodies, but in military practice injuries inflicted by frag- 
ments of shell, cannon-balls, grape, shrapnel and canister shot, or splin- 
ters of wood or stone set in motion by large shot, are included under 
gunshot wounds. Injuries produced by flying pieces of caps and ex- 
ploded gun-barrels are also spoken of as gunshot wounds. 

Missiles. — Shot ranges in size from dust, each pellet weighing -^ of 
a grain, to buckshot, weighing 153 grains. Pistol-balls are of a calibre 
from .22 to .45 inch, and weigh from 25 to 250 grains. All modern 
missiles approach a conical form. They may be pure lead (compressed 
into shape, not cast) or be hardened by the addition of from 2.5 to 5 per 
cent, of tin. In addition, military projectiles are covered by a thin cover- 
ing (jacket or mantle) of steel, nickel, copper, or alloys of copper and 
nickel, or copper, nickel, and zinc (Maillechort). 

Formerly of a calibre of .50 to .71 inch and weighing from 400 to 760 grains, 
the most recent missiles vary in length from 3.5 to 4 calibres and in weight from 
150 grains (calibre .256 inch) to 245 grains (calibre .315 inch), the former attaining 
a velocity of 2329 feet per second, the latter 1984. The old Springfield ball (calibre 
.45, weight 500 grains) of the U. S. service, with 70 grains of black powder attained 
a velocity of only 1300 feet, but the new weapon, recently adopted (calibre .30, 
weight 220 grains), propels a ball 2000 feet per second. 

Effects of Modern Bullets on the Tissues. — Great care must be 
exercised in drawing conclusions from the experimental results obtained 
on the cadaver with reduced charges at fixed distances (La Garde, 1 
Habart, Seydel). The differences between the actual velocity and 
angle of incidence with reduced charges at fixed distances and service 
charges at actual distances are marked. The tension of living muscles 
and fascia? as compared with dead tissues, and the phvsical change from 
the semi-liquid fat of adipose tissue and of medulla to a more solid con- 
dition by the loss of animal heat, influences the results. The velocity, 
form, size of ball, and time the injury is inflicted after leaving the weapon 
modify the tissue-damage. Elastic structures, as skin, may be merely 
split ; less elastic ones, as fascia?, muscle, and bones, are more or less 
destroyed for a varying distance around the track of the ball. As Conner 
points out, the gross anatomical structure may limit the destruction, as 
in a muscle longitudinally traversed, when " the track may be traced with 
great difficulty or not at all," owing to the separation, not destruction, 

1 Report of Swg.-Gen. of the Army to Secretary of War, 1893, p. 73. 
264 



GUNSHOT WOUNDS. 



265 



of the fibres. It has been confidently asserted that the old missiles pro- 
duced more primary and secondary destruction of tissue than the modern 
balls. Actual experience in warfare has demonstrated the more humane 
effect of jacketed balls. The zone of " explosive action " is indeed 
increased, extending probably up to at least 500 yards ; but Demosthen's 



Fig. 75. 



Fig. 76. 



Wound inflicted at about 110 yards (from a 
recent foreign report). 1 



Wound inflicted at 1300 yards by steel-mantled 
ball (from a recent foreign report). 



dictum that in the case of the skull there is practically no distance up 
to 1300 yards or more where " explosive action " is not marked, has been 
disproved by the experience of the late war. A few remarks concern- 
ing certain facts of ballistics will explain many of the foregoing state- 
ments and others which will be made later. The remarkable initial 
velocity attained by modern small-bore projectiles, which when arrested 
develops such enormous " energy," has seemed to obscure the fact of the 

1 By request of the gentlemen to whom the author is indebted for permission to use 
these illustrations the exact source is not credited. 



266 INJURY AND REPAIR. 

great " energy " of the older weapons. Thus the Krag-Jorgensen de- 
velops less than a third greater muzzle energy than the Springfield. 
Surprise is expressed at the trivial, almost incised character of most 
flesh-wounds ; but this should have been anticipated, because with such 
immense velocity, if little resistance is experienced, the missile will retain 
nearly all its " energy," imparting practically none to the tissues, hence 
the devitalization of the walls of the ball track is reduced to a minimum. 
Although doubling the velocity of a projectile quadruples its "energy" 
as compared with that of another of similar weight moving with half 
the velocity, it seems too often forgotten that doubling the mass also 
doubles the " energy," so that when the velocity with which the lighter 
ball moves approximates that of the heavier ball, the " energy " of the 
heavier missile is often actually much greater than that of the lighter, 
more rapidly moving projectile. Seeing the tremendous effects produced 
by modern bullets impinging at short ranges, many have overlooked the 
retarding effects of the atmosphere upon velocity, and have rashly con- 
cluded that in the mid-ranges the velocity so greatly exceeds that at- 
tained by the older weapons that much greater disruption of tissues, 
rarity of lodgement, and of deflection must occur than has been actually 
observed. In war nearly all the wounds are received at a distance of 
from 800 to 1000 yards. The infrequency of deforming of the balls 
lessens destruction, because the arrested velocity caused by the resistance 
producing the deformity results in "conversion of the energy" into 
motion imparted to the detached fragments of tissues and liquid par- 
ticles, converting them into " secondary missiles," these, with the effects 
of the radiation of the imparted motion to the stabile portions of the 
tissues, causing the "explosive action." The "hydraulic" or "hydro- 
dynamic " theory is readily disposed of by the following two facts, viz., 
a projectile fired through a sealed leaden vessel filled with water will 
emerge exactly opposite the point of entrance, despite the rending of the 
vessel into fragments, which would be impossible if hydraulic pressure 
had torn the vessel apart : still further, the same results follow the pas- 
sage of a ball through a second leaden vessel filled with water the whole 
of the top of which is open, hence one in which no hydraulic pressure 
can possibly be developed. Hence " diverted energy arrested " is amply 
sufficient to account for all the " explosive effects " resulting from the 
impact of a ball starting at the rate of over 1 500 miles an hour (Mauser) 
and developing a " muzzle energy " of 89.543 ft. lbs. Penetration de- 
pends chiefly upon " remaining velocity," an unchanged form of the 
missile, and the lack of resistance. Let the last be marked, and defor- 
mation will be probable, which in conjunction with the arrested velocity 
will produce " explosive effects." The increasing curve described by 
the trajectory of a ball causes it, at 1000 to 1500 yards, to strike the 
tense skin, fascia, and inclined planes presented by many bones, at a 
decided angle : moreover, the greater length of one diameter favors tilt- 
ing, hence impact against skin has been sufficient at times to cause a 
Mauser ball to traverse two thighs sideways, producing a " key-hole " 
wound. This would be impossible if the ball possessed its "initial 
energy ;" but at 1000 yards the " remaining energy " is only about one- 
sixth, while at 1500 yards it is little more than one-ninth, at both of 
which distances the Springfield actually possesses much more energy 



GUNSHOT WOUNDS. 



267 



than the Krag or Mauser, yet none would be surprised at the Springfield 
projectile either lodging or being deflected at such range. If no bony re- 
sistance is met with, or but little — as cancellous bone — beyond 350 yards, 
the wounds are more apt to be perforations, without much comminution 
of bone and laceration of soft parts, than with the old balls. If much 
bony resistance is met with at short ranges, the ball often does become 
deformed (see Fig. 77) ; at 1000 yards and over, jacketed balls are not often 
deformed, but bone comminution is apt to be extensive, although with 
comparatively slight displacement of the fragments. Perforation rather 
than lodgement has been the rule at the usual ranges at which wounds 
are received, but lodgement occurred quite often during the Santiago 
campaign, 10 per cent, being a conservative estimate. Primary hemor- 
rhage and division of nerves did not appear to be more common than 
with the old balls, slight wounding and in a few instances apparently 
pushing aside of large vessels were observed at about 1000 yards range. 




o, completely shattered after perforating a horse's thigh-bone at 220 yards ; steel mantle stripped ; 
b, ball with mantle torn off and rolled up, core deformed, after shattering human tibia at 60 
yards ; c, wholly disorganized ball, which destroyed middle metatarsal bone of horse at 660 yards, 
steel-mantled; d, ball which shattered a human femur at about 7n0 yards, steel- mantled ; e, 
remains of steel mantle and part of core lodged in human femur, wound inflicted at about 
3100 yards ; /, g, fragments of mantle found near the orifice of the wound of exit at about 1100 
yards' range, steel-mantled ; h, piece of steel mantle split off by striking a dried horse's met- 
atarsal 'at over 1800 yards ; i, steel-mantled ball which perforated the internal femoral condyle 
and lodged beneath the skin at nearly 2200 yards. (Recent foreign report.) 

Experimentally, at least 10 per cent, of the German-silver jackets 
parted entirely from their cores at ranges of from 100 to 2000 yards if 
bony resistance was met with, and this was also measurably true for the 
Maillechort mantle of the Mauser in actual warfare. Steel jackets are 
less apt to strip, yet Fig. 77 (e, f, g, and h) shows deformation and 
stripping at over 1 100 yards when dense bone was encountered. Ball 



268 



INJUJRY AND REPAIR. 



wounds are usually contused wounds, although laceration may be added. 
Grazing of surfaces or contusion without skin penetration may occur 
with pistol-balls or even spent rifle-balls, but perforation or penetration 
with lodgement is most common. The wound of exit with the old 
balls was apt to be larger and more irregular than that of entrance ; 
but those made by the new balls, when they involve the soft parts 
alone, are about the size of the projectile, sometimes smaller, some- 
times larger. Unless within the " zone of explosive action," the 
wound of exit is often not appreciably larger than that of entrance, 
even sometimes when a bone has been traversed ; but within the 
"explosive zone" the difference is often very marked. The wound 
of entrance has often a contused, discolored margin, and is depressed, 
while that of exit is everted and stellate, triangular, or linear. 
Powder-staining, owing to differences in powder, varies, the distance 

Fig. 78. 




Multiple shot-wounds of arms and back. The opening over the spine was produced by pressure 
not by the ball (case in Cincinnati Hospital, 1S84). (Conner, Dennis's System of Surgery.) 

of the muzzle from the part having been in reported cases from two 
to ten feet. Whether any analogous marking will occur with the 
new powders remains to be shown. Deflection of the modern conical 
pistol-ball is unusual as compared with the old round ball, and this is 
still more true of the mantled rifle-ball. Moreover, it must not be 
forgotten that change of position of a part or the body after the 
reception of a wound may closely simulate deflection of the ball. 
One bullet may cause " nine wounds," ' or, if lodging, three four 

1 Personal experience. 



GUNSHOT WOUNDS. 269 

etc. ' (Fig. 78). Splitting of the old, soft-lead ball sometimes caused 
two wounds of exit, but this will rarely occur with the hardened pistol 
or jacketed rifle projectile. The truth, that " when a bullet has censed to 
move it has ceased to do harm," has but few exceptions. When lodged 
in the brain it may primarily, or, by changing its position from gravity, 
secondarily, cause dangerous pressure-symptoms. Again, a ball may 
ulcerate its way into a hollow viscus or blood-vessel when in contact 
with one of these. Lodged in the soft parts, a bullet usually promptly 
becomes fixed by the development of a connective-tissue capsule, 
although sometimes a change of position is effected by gravity or mus- 
cular action. One wound usually indicates lodgement, but the missile 
may have passed out by a natural opening, as the mouth or rectum. 
Again, the old-fashioned round ball — still occasionally employed — 
sometimes carries ahead of it for a short distance into the tissues a 
pouch of clothing, upon the withdrawal of which the ball is extracted 
and may be overlooked. 

Determination of the Location of Balls. — Palpation and explora- 
tion with the finger or probe — electric or simple — are the means to be 
employed, and the X-rays when time permits. The disinfected finger 
is the best probe if the track be large enough. Pistol-balls which cannot 
be detected by palpation had better be left without further search unless 
the brain or a hollow viscus have been wounded. The only warrant for 
the enlargement of a wound is the probable lodgement of a fragment of 
clothing, since the finger alone can distinguish any textile fabric from 
the soft tissues. 

A bullet-probe should be of meta) and have as large an extremity as the ball- 
track will admit. Aluminum is light and useful for brain-wounds, but must not 
be placed in strong bichloride solutions. Nttaton's porcelain-tipped probe may 
prove useful, but if a bone have been struck or traversed it may mislead, frag- 
ments of lead often adhering to the bone and marking the probe; moreover, a 
jacketed ball, unless approached from its butt end, cannot mark this probe, because 
no lead is elsewhere exposed. Girdner's telephonic probe seems to be the best of 
the electrical devices, but its exact value has not yet been determined. 2 Even 
when located it is not always advisable to remove balls. When their continued 
presence is likely to be more hazardous than their removal, operate : when this is 
in doubt and much damage will result from their extraction, let any missile alone. 
Extraction may be effected through the track of the ball or by a counter-opening, 
being guided by anatomical conditions and the superior facility of manipulation 
afforded by one method over the other. Fixation while being cut upon and free 
exposure are requisite when removing a ball by counter-incision. 

Hemorrhage. — This may be free, but is speedily arrested by natural 
processes unless a vessel of some magnitude is opened ; but a large pro- 
portion of deaths from gunshot wounds result from primary hemorrhage 
caused by wounds of the great vessels. It is surprising, in exceptional 
cases, to see how such wounds as those of the jugular, carotid, vertebral, 3 

1 Conner, Dennis' s System of Surgery, vol. i. p. 448. I would here acknowledge my great 
indebtedness for much information and many valuable facts to Prof. P. S. Conner's article 
on "Gunsliot Wounds" in the work just quoted from. 

2 Park, ' ' Some Considerations concerning Location and Detection of Missiles," Medi- 
cine, June, 1895. 

3 The writer has seen one case where the jugular vein, carotid, and vertebral arteries 
were wounded, and successfully operated upon by a colleague more than two days after 
injury, death eventually resulting from cerebral softening: more than one subclavian, 
brachial, and femoral artery in the late war were wounded, the patients living without 
external hemorrhage for days — even weeks. 



270 INJURY AND REPAIR. 

subclavian, external and internal iliac, etc. may not prove fatal for 
hours or even days. The new bullets give rise to more severe primary 
hemorrhage, while asepsis lessens the frequency of secondary hemor- 
rhage, which is largely, although not entirely, dependent upon sepsis. 

Pain. — This is variable ; but unless a large nerve be struck it is dull 
or tingling, or like a smart cut with a cane. During great mental 
excitement no pain may be at first noticed. 

Shock. — Although ball-injuries involving the brain, spinal cord, 
abdomen (solar plexus) : are usually attended with marked shock, this 
is not invariably true. The author has seen marked symptoms from a 
comparatively trivial wound of an extremity, and after pistol-ball 
wounds of the brain or abdomen but little disturbance. 

Prognosis. — This depends upon the size of the missile, its velocity, 
the parts injured, and the degree of asepsis observed during the first 
examination and dressing, for, as Nussbaum justly observes, "the fate 
of a wounded man is in the hands of the surgeon who first attends him." 
Cceteris paribus, a pistol-ball wound of the same structures will not be 
so dangerous as that inflicted by the bullet of a military rifle. The 
primary dangers of shock and hemorrhage being survived, sepsis with 
possible consequent secondary hemorrhage is alone to be feared ; hence 
the early aseptic treatment possible in civil practice renders gunshot 
injuries less fatal than those received in war. The majority of 
bullets being aseptic, the wounds they inflict will usually remain so, 
unless fragments of clothing or an unclean finger or instrument become 
a vehicle of infection. Theoretically, germs may reach a wound by 
way of the circulation, having gained access thereto by a distant infec- 
tion-atrium. In practice this can be ignored. Proper disinfection of 
the environment of the wound, with rigid exclusion of all infected 
instruments, hands, and sponges, must be enforced in civil, 2 and so far 
as possible in military practice, since experience demonstrates how much 
gunshot mortality can thereby be diminished. 

Small-shot "Wounds. — These include all those not produced by bul- 
lets proper, even " buckshot." At close range a charge of the smallest 
shot will act as a solid mass, making a large track through the soft 
parts and the bones. If the vascular supply is not too extensively 
destroyed by laceration of the soft parts, even with free comminution of 
bone, the part can often be saved, but when serious damage to vessels 
and nerves also exist it is a grave question whether the limb will be 
worth saving at the cost of great peril to life. Conservatism is more 
warrantable for injuries of the upper extremity than the lower, because 
a hand on a maimed arm is valuable, while a sound foot on a leg in- 
capable of bearing weight is only a useless incumbrance. 

Typical or atypical resection can often be substituted for amputation especially 
for injuries of the elbow- and shoulder-joints. If the shot-charge is received 
at a greater distance than a few feet, the destruction is rarely such as demands 
operation other than removal, when possible, of shot, loosened fragments of bone, 

' Injuries of the basal ganglia, cord above the phrenics, the medulla oblongata, and 
the solar plexus, especially with modern balls, are probably instantly or almost instantly 
iatal, so that after such wounds it may safely be affirmed that the individual had been 
incapable of inflicting harm upon himself or others— a point of medico-legal importance 

Mn the late Spanish-American war the wonderful success attending "antiseptic 
occlusion by means of the "first-aid package" has demonstrated the possibility of 
securing efficient asepsis on the battle-field. 



WOUNDS. 271 

shreds of clothing, etc. Of course, eyes may be destroyed, the larynx wounded, 
the great cervical vessels be perforated, or even the spinal cord be severed by a 
single small shot fired at a distance. 

General Considerations as to Treatment. — Asepsis should be 
the one end in view after any hemorrhage has been temporarily arrested. 
Disinfection of the surrounding area must be carefully effected, after 
which any necessary exploration of the wound may be made, 1 hemor- 
rhage permanently arrested, and foreign bodies, including bullets, 
removed if deemed advisable. Simple "antiseptic occlusion" should 
always be employed by preference, unless exploration has been done. 
Disinfection of the ball-track should only be done when it has been 
explored or if it is an extensive one, as the wound of exit sometimes is 
within the "zone of explosive action." Asepsis is favored by mini- 
mizing further damage to the tissues by securing rest for the parts by 
splints, etc. Patients wounded by modern pistol- and rifle-balls will 
usually recover if asepsis be maintained, unless some complication, as a 
serious visceral wound, coexist. Healing of the ball-track is usually 
said to commence in its central portion and proceed thence toward the 
wounds of entrance and exit, the former commonly healing last. When 
only the soft parts are compromised, aseptic healing often occurs or 
only a little pus is formed : this may even occur when bone lesions 
coexist. 

Injuries of Soft Parts. — The skin, struck at a proper angle, may 
be merely grazed, and if the ball be "spent" a mere linear contusion 
results ; but if moving with more velocity or at a different angle, the 
ball may just penetrate the integument. An appearance simulating the 
linear bruise inflicted by a severe cut with a whip follows the passage 
of a ball between the skin and deeper structures. The subsequent 
destruction and separation by sloughing of the tissues after such a 
wound will leave a depressed groove, and later a similar scar. Grazing 
by cannon-balls or large fragments of shells, or more commonly impact 
of a nearly "spent" large projectile, may leave the skin intact, but dis- 
organize all the other tissues of a limb, or the viscera if the walls of 
a cavity be concerned. With dry aseptic dressings skin-grazes or con- 
tusions, producing even sloughing of a portion or the whole thickness of 
the skin, will heal readily without suppuration. Deflections even of 
pistol-balls by fancies are now rare, and modern rifle-balls at close range 
are never thus turned from their course. The openings made by perfora- 
tions of fasciae being due to separation as well as division of fibres partial 
closure takes place, rendering it difficult to follow the track of the ball 
and also interfering with drainage. Imperfect healing of fascial wounds 
may lead to hernia of muscle, but this will be much less likely to follow 
wounds inflicted by the modern small-calibre missiles than with the old 
large balls. Severe damage to muscles is only caused when balls strike 
at short range — i. e. within the zone of " explosive action." Wounds 
parallel to the course of muscular fibres often separate rather than divide 
them ; hence the difficulty or impossibility of following such a track 
with a probe ; but passing at right angles to the fibres, their division 
naust take place. Large shot or fragments of shells produce much 

1 Exploration should never be done unless absolutely requisite, as it adds to the 
chance of infection. 



272 INJURY AND REPAIR. 

destruction and sloughing, often causing serious deformities by scar-trac- 
tion. The belly of a muscle may be ruptured by a bullet striking, but 
not penetrating, its tendon. Tendons may be perforated or divided, or a 
segment may be removed. Modern jacketed bullets rarely simply con- 
tuse vessels, but partial or complete division is the rule. Secondary 
hemorrhage, the formation of an aneurism or an arterio-venons aneurism 
— when an adjoining artery and vein are injured — may follow slight 
vascular wounds. Nerves more commonly escape complete division than 
vessels, but partial division and contusion often lead to late trophic 
changes with partial or complete abolition of function. 

Injuries of bones and joints comprise nearly one-fourth of mili- 
tary gunshot wounds, but are much less common and severe in civil 
life, because usually inflicted by small pistol-balls moving with compar- 
atively low velocities. Pistol-balls and spent rifle-balls may simply 
contuse bones, the result depending upon whether merely subperiosteal 
effusion is produced or the vessels in the bone-tissue are ruptured. In 
the latter event necrosis may result, especially if infection occurs. 
Bone-contusions will probably be rare with modern projectiles, and 
under aseptic treatment should recover without local or general infec- 
tion, thickenings, or neuralgias, as was so common in the past. 

Bones may be fissured, divided into two or more fragments, or may 
be partially or completely perforated. Slight Assuring is doubtless often 
overlooked, owing to the difficulty of diagnosis. The fissure may extend 
obliquely or transversely across a bone, even producing complete frac- 
ture without rupture of the periosteum. The fragments may never 
separate or attempts at walking may later displace them. Most ball- 
fractures are by penetration ; a portion of the osseous tissue, being driven 
in or more or less finely pulverized, is scattered along the ball-track 
(Fig. 79), lines of fracture usually radiating from the main focus. 

The comminution varies, being in proportion to the velocity of the ball and the 
resistance met with, but in a long bone does not usually extend through the epiphys- 
eal ends. The fragments may be completely detached or partially adherent by 
periosteum. Pistol-balls may imbed themselves in bone, but this accident will be 
excessively rare with rifle projectiles. Except at short ranges, modern balls com- 
paratively cleanly perforate long bones at or near their cancellous ends with little 
Assuring. Flat bones are more apt to be perforated with extensive shattering. 
Within the " explosive zone," when a resistant bone is struck, there will be great 
loss of bone-tissue, the fragments being driven in all directions, backward as well 
as onward and to either side, producing widespread pulpefaction of the soft parts. 
The wound of exit is really a bursting outward of the skin by the force acting 
from within, the track being conical, with the apex at the site of the fracture. 
Sometimes the wound exceeds six inches in length and four in breadth, bone-frag- 
ments in addition occasionally piercing the skin outside the main laceration. 1 At 
from 1200 to 1500 yards perforation with comminution is apt to occur, but the fragments 
are not much displaced. Beyond these ranges, so long as the ball possesses momentum 
enough to fracture, comminution becomes less and less marked. A ball crossing a 
bony crest or at a tangent to a curved surface may cut a clean groove, but may in 
addition fissure. A soft-lead ball may split on a bony crest or even the convexity 
of the cranium. This accident will rarely occur with hardened pistol-balls, and 
will be still more improbable with jacketed rifle-balls. Fracture by penetration or 
perforation is present if bone-fragments or dust be found in either wound, espe- 
cially that of exit, and if this be decidedly larger than that of entrance. Of course, 
if the ordinary symptoms of fracture are detectable, the diagnosis is clear. When 
the direction pursued by the ball renders it nearly certain that fracture by pene- 

1 Conner, op. cit. 



GUNSHOT WOUNDS. 



273 



tration exists, it is safer to act upon this hypothesis, lest displacement with addi- 
tional injury be produced by manipulation. 

Treatment. — Render the wound-orifices and surrounding skin 
axeptic, and then the accessible portion of the track ; dress by " antiseptic 
occlusion" and immobilize the parts. 

More extensive bone-injuries require the same preliminaries, possibly 

Fig. 79. 





Shattering of humerus at long range with modern projectile ; fusible metal east showing extent 
and character of laceration of soft parts (from a recent foreign report). 

followed by aseptic removal of all completely detached fragments, 
moulding into place of attached fragments, disinfection, drainage, care- 
ful fixation of the parts, and antiseptic dressings. Most extensive com- 
minutions of the humerus and femur do better by simple occlusion and 
fixation than by exploration and removal of fragments, which if asepsis be 
maintained become consolidated in the callus: if exploration has been made, 
loose fragments had better be removed and drainage instituted. When an 
impacted ball can be easily reached, it should be removed, but if much 
additional injury would result from its extraction, it had better be 
left, for although no heat sufficient to render a ball aseptic is devel- 
oped either during firing or by its passage through the tissues, yet the 
majority of projectiles " are either sterile or free from septic germs." 
Great destruction of bone and soft parts by balls wounding within the 

18 



274 INJURY AND REPAIR. 

" zone of explosion," those by charges of small shot at short ranges, 
etc., must be treated as similar compound fractures otherwise induced. 
If the destruction of bone and soft parts is so great that the limb must 
prove useless if saved, or if the main vessel or vessels are divided, with 
such damage to the tissues through which the collateral circulation 
must be established that gangrene will occur or repair almost certainly 
fail, amputation should be done. When in doubt, especially in civil 
practice, tie all bleeding vessels, extract loose bone-fragments, replace 
attached ones, disinfect, drain by numerous counter-openings and tubes, 
and immobilize, amputating later if gangrene or infective osteomyelitis 
occur. These rules sometimes require modification in military practice, 
because prompt and effective antisepsis with proper after-care of the 
wounded is at times impossible. 

Wounds of Joints. — Wounds of the soft parts over a joint may, 
if they become infected, secondarily set up intra-articular trouble. 
Wounds of bursa; will lead to similar results if they communicate with a 
neighboring joint, as they so often do. If the wounds of entrance and 
exit indicate perforation of a joint by a modern small-calibre ball, such 
an injury may be confidently affirmed. A ball traversing a joint usually 
perforates, crushes, splinters, or grooves one or all of the component 
bones, but the synovial membrane may alone be penetrated. Extra- 
articular bony fissures may tear the synovial membrane, or secondary 
penetration may result from septic ulceration extending from an infected 
fissure. 

Diagnosis. — With free destruction of soft parts, as by a fragment 
of shell, this is easy. Extensive bone-comminution near a joint, fol- 
lowed by rapid distention of the articulation from accumulation of blood, 
escape of bloody synovia, or the presence of bone-dust or fragments in 
the wound of exit, readily decide the question of joint-wound. In the 
absence of these symptoms the relative position of the wounds of en- 
trance and exit and the free escape of synovia must be depended upon. 
The probe should be avoided as a means of diagnosis. When doubt 
exists treat the case as one certainly involving the joint. 

Prognosis. — Death should rarely occur from an uncomplicated joints 
wound in civil practice, but the prompt and successful employment of 
asepsis in military surgery is so often impossible that the mortality in the 
past has been as high as 12.9 per cent, for mere wrist-joint wounds. 
Modern methods have diminished this mortality, 1 as well as the fre- 
quency and extent of the ankylosis formerly so common when con- 
servatism was attempted. 

Treatment. — This may be conservative, especially for bullet wounds ; 
atypical excision may be done or the limb be amputated. Conservatism 
means thorough disinfection of the surrounding parts and the wound- 
orifices, followed by " antiseptic occlusion " and fixation. Formal ex- 
cision as a primary measure has not given as good results as the conser- 
vative procedures just advocated, and should be abandoned. If resulting 
from shrapnel, grape, or shell wounds, free disinfection, removal of frag- 
ments, drainage, and fixation are indicated. 

Wounds of the Head. — The scalp may alone be wounded, con- 

1 More than 20 wounds of the knee-joint were successfully treated at the Divisional 
Hospital, Siboney, during the Santiago campaign. 



GUNSHOT WOUNDS. 275 

tusions, lacerations, or penetration and lodgement resulting. Pistol- 
balls often lodge, especially in the temporal muscle ; but rifle-balls rarely, 
if ever. 

Treatment. — The probe, X-rays, or palpation will locate the ball. 
When imbedded in the temporal muscle, pain on moving the jaw or upon 
pressure over the zygoma may guide the surgeon. 

Considerable hemorrhage may occur from wounds of the temporal or occipital 
arteries, or a cephalhematoma may form, presenting some superficial resemblances 
to a depressed fracture. If absorption of these blood-effusions does not take place, 
antiseptic aspiration or incision is indicated. Unsuspected intracranial lesions 
produced by impact of the ball on the cranial vault may prove serious, but mere 
osseous. contusion, treated antiseptically, should no longer give rise to the neural- 
gias, headaches, etc. so common in the past. 

Injuries of the Cranial Bones.- — Contusions may be produced by 
nearly-spent balls or those striking at a tangent, but with the new bul- 
lets such lesions will be rare, fracture or grooving being nearly certain. 
If asepsis be maintained, usually only plastic exudate follows, although 
quiet necrosis may result. If infection occurs, osteomyelitis may cause 
necrosis of the external table alone or more rarely of the whole thick- 
ness of the bone. Infective inflammation of the diploe is a not uncom- 
mon sequence of contusion. This may cause subcranial suppuration, 
septic encephalitis, or general pyasmia. Fracture of the internal table 
of the skull is also possible. (Vide, also, Chapter XXXVIII.) 

Diagnosis. — This may be made by inspection or the probe, but 
where the former is impossible it is safer to infer the lesion of the bone 
by the course of the ball, unless its removal or the arrest of hemorrhage 
demands exploration of the wound. 

Treatment. — Strict asepsis, if instituted early enough, will prevent 
any septic complications. If these arise, incisions, removal of infected 
bone, opening of cerebral abscesses, disinfection, and drainage are indi- 
cated. 

Penetrating gunshot injuries cause more serious intracranial lesions 
than follow other traumatisms, that which appears but a mere fissure 
having often been produced by marked temporary depression of both 
tables, as shown by a tuft of scalp-hairs imprisoned in the capillary 
crack or a fragment of a ball lodged within the cranium. 

Widespread shatterings, especially those involving the base, result 
from extension of fissures and conduction and amplification of vibrations 
by thickened bony ridges. The base is seldom fractured by diverted 
energy, although the ethmoid and the orbital plates of the frontal may 
yield. Pistol-balls rarely produce this, but these same plates are some- 
times thus broken. Sudden death, caused by disorganization or removal 
of large portions of the skull and brain by cannon-balls or charges of 
shot, etc., sometimes gives rise to traumatic cataleptic rigidity — i. e., post- 
mortem rigidity rapidly produced, which maintains the body in the posi- 
tion when struck. 

Prognosis. — This is most serious, early death resulting in fully one- 
half from shock and hemorrhage. When the ball (pistol) was removed, 
according to Bradford, 33.33 per cent, recovered ; when it was left, 46 
per cent. Expectancy gave in 25 cases a mortality of 52 per cent. 
Wounds involving only the frontal lobes with lodgement of the ball 
seem less dangerous than those of the more posterior portions of the 



276 INJURY AND REPAIR. 

brain. Cerebellar lesions are usually rapidly fatal. Transverse wounds, 
passing laterally through or near the ear, are more dangerous than 
antero-posterior ones. Infective intracranial inflammations, leading to 
localized (abscess) or diffused suppurations and hernia cerebri are the 
late causes of death : these are avoidable if asepsis be secured. Division 
of one or more of the cranial nerves and various late perversions of 
cerebral function, as epilepsy, headaches, and insanity, are possible se- 
quences, as after other head-injuries. Balls do not usually become 
encysted, but change their position in time by gravity. If while migrat- 
ing they encounter portions of the brain governing important functions, 
serious trouble is sure to arise, even many years after injury. 

Diagnosis. — This must be made by inspection and palpation ; probing 
should be avoided unless absolutely requisite. The aid of the X-rays 
may also be invoked. 

Treatment. — As infection is the sole lethal cause" if primary hem- 
orrhage and shock do not cause death, disinfection and drainage are the 
indications. The wound or wounds should be protected by antiseptic 
compresses, and (preferably) the whole scalp carefully shaved and dis- 
infected ; finally the wound itself should be cleansed. Fracture or pene- 
tration having been determined by the proper means, a flap should be 
reflected and the damaged bone (probably infected) be removed, hemor- 
rhage be arrested by ligation, forcipressure, 1 or possibly a gauze tampon. 
The wound of exit must be treated in the same manner. One drainage- 
tube, or two meeting in the centre of the track must be carefully intro- 
duced, and gentle irrigation with sterilized water employed. Such pro- 
cedures should only be adopted when a distinct indication exists, as ex- 
tensive bone-shattering with depression of fragments, hemorrhage dan- 
gerous from its amount or because exerting pressure, or probable infec- 
tion from foreign bodies. When the ball has lodged, after the prelimi- 
naries described, it may be sought for by an aluminum probe or a medium- 
sized elastic bougie. Except when exploration has been done, drainage 
tubes are not indicated, antiseptic occlusion serving a better purpose. 

The effect of gravity should be invoked to aid the progress of any probe, 
because a false passage is so readily made through the cerebral tissue. Probably 
the telephonic probe would here work to most advantage. If the probe passes 
readily to the opposite side of the skull, careful palpation may reveal the presence 
of the ball beneath the scalp, a fracture, or an ecchymosis if the head has been 
shaved. None of these three conditions being found, trephining should be done 
over the end of the probe and the ball sought within the cranium above, below, 
to one side or the other of the opening. After the failure of such an amount of 
search as can do no serious injury to the brain, it is better to desist from further 
manipulations beyond depositing a drainage-tube in the track and carefully irri- 
gating it. Localizing symptoms may indicate the course of a ball, but rarely its 
location, and unless detected very shortly after the reception of the injury are apt 
to be misleading, owing to slowly-extending hemorrhage. Even immediately after 
the wounding the localizing symptoms are often deceptive, owing to the wide- 
spread injury outside the actual ball-track. Voluminous dressings are usually 
requisite on account of the free escape of cerebrospinal fluid. Fracture without 
penetration requires the treatment adapted to any compound fracture of equal 
severity. 

1 Fine wire serres-fines, with attached ligatures, may be left in situ for days if liga- 
tures cannot be made to hold. Cerebral vessels being deficient in sheaths, it is difficult to 
ligate them ; only enough tension should be put upon the first half of the knot to occlude 
the lumen of the vessel. 



GUNSHOT WOUNDS. Til 

Pace. — Primary or secondary hemorrhage is the chief danger, al- 
though destruction of parts and extensive scarring may result, especially 
from small-shot wounds. Pistol-balls, except at short range, do not 
shatter the facial bones much, 1 and probably the new rifle-bullets will 
not, at least in the middle ranges. Balls may pursue most erratic 
courses, penetrating the face to emerge by nostril or mouth, without 
doing any or but slight damage — traversing the orbit or mouth 
without injuring eye or tongue. Bullets travelling from before back- 
ward through the face often wound the brain, spinal cord, or great 
vessels. Transverse wounds, especially those involving the lower jaw, 
are often complicated by division of one or more of the larger vessels. 
Pistol balls often lodge in the orbit, nasal fossae, or antrum. Bullets 
passing through the back of the orbits may wound or divide one or both 
optic nerves. 2 Those injuries of the supraorbital regions leading to 
blindness, formerly attributed to damage to the supraorbital nerve, are 
generally due to a fissure traversing the optic foramen and destroying 
the nerve. Furrowing or perforation of the tongue is not uncommon. 
Fragments of, or whole, teeth are sometimes driven into the tongue ; 
more rarely the ball itself lodges. Although often productive of such 
swelling as to interfere with speech, deglutition, or even respiration, 
tongue-wounds are not usually dangerous unless the lingual artery be 
wounded. 

Treatment. — Ligate vessels ; extract teeth, pieces of bone, or a 
ball imbedded in the tongue ; remove neither attached bone-fragments 
nor contused soft parts ; mould the hard parts into place ; maintain all 
in situ by sutures, antiseptic compresses, or tampons, or by interdental 
splints. Secure all the asepsis possible by irrigation, non-poisonous 
mouth-washes, and sprays. 

Neck. — Wounds in front of the sterno-mastoid muscles must, when 
deep, compromise important structures, as the trachea, oesophagus, great 
vessels, and nerves, with all their primary and remote dangers. Those 
posterior to these muscles, although possibly involving the spine, are 
usually only muscle-wounds. 

Prognosis. — Hemorrhage, often late, and suppuration, which unless 
early evacuated will extend, directed by the cellular planes into the 
thorax or axilla, are the chief dangers. 

Treatment. — Primary hemorrhage (rarely seen) must be treated by 
ligation in the wound, if possible, when arterial ; by compression if 
venous, unless the deep jugular be wounded, when ligation should be 
done. Too often the vessel cannot be secured in the wound, when both 
carotids should be exposed, and if compression of the external arrests 
the bleeding it should be tied ; if not, the internal must be secured. 
Wound of the vertebral above the sixth cervical vertebra can better be 
controlled by efficient tamponade. Wounds of more than one vessel 
are not unusual, as carotid, jugular, and vertebral, and with a small 
external wound, as by a pistol-ball, such an injury of the great vessels 
has been found compatible with several days of life, a traumatic aneurism 
or arterio-venous aneurism forming. If a ball so lodge as to cause irri- 

1 Except the lower jaw. 

2 The present Supt. of the TJ. S. Military Academy lost the vision of one eye, and at 
first both nerves were thought to have been divided. 



278 INJURY AND REPAIR. 

tation or paralysis of nerves by pressure, its removal will probably 
ameliorate or relieve the trouble. The larynx or trachea may be merely 
contused by a bullet, causing pain, dyspnoea, and bloody expectoration, 
with cough. If penetrated, emphysema or the external escape of air is 
superadded. When the oesophagus or pharynx is also opened, food is 
apt to escape from the wound, although this may be due not to an abnor- 
mal opening in the gullet, but to improper action of the epiglottis, so 
common after tracheotomy. Hemorrhage into the trachea, or, occurring 
later, oedema glottidis, may cause death. Dangerous pressure may also 
be exerted from without upon the trachea by blood or inflammatory 
exudate. After recovery impairment of the voice is apt to persist. 
Ligation, suturing, tamponade, or the actual cautery may become 
requisite to arrest bleeding if the thyroid body is wounded. 

Treatment. — Eemove the ball if lodged, secure asepsis for the 
wound, and employ early intubation or tracheotomy if the respiration 
is seriously interfered with. Suture, or, if this is impossible, plugging, 
of any oesophageal or pharyngeal wound is necessary to prevent infec- 
tion, employing for the same reason the oesophageal tube for feeding. 
Later, necrosis of cartilage may occur, aerial fistula may persist, or more 
rarely stricture may form. 

Spinal Column. — The ball or fragment of shell may contuse a ver- 
tebra, fracture any portion of it (usually a spinous process), wound the 
meninges or cord, or be a complication of cervical, thoracic, abdominal, 
or pelvic perforation. 

Symptoms. — Shock is great. When the cord is damaged there is 
impairment or destruction of function according to the location and 
extent of the primary contusion or laceration or the secondary com- 
pression by blood and inflammatory exudate. Very rarely cerebro- 
spinal fluid escapes from the wound, proving that at least the membranes 
have been opened. Hemorrhage external to or within the membranes, 
and possibly within the substance of the cord, if slight may, after tem- 
porary pain and paralysis, end in complete recovery. Large effusions 
are apt to end in infectious myelitis, the chief danger in all spinal inju- 
ries. Evidences of severe and lasting damage to the cord when life is 
spared are most commonly due to bone-fragments, or, exceptionally, to 
lodgement of the ball. 

Prognosis. — Where the membranes have been opened, much worse 
perforated, some compression or laceration of the cord must result. In 
military surgery infective myelitis usually destroys life, but in civil prac- 
tice cases receive effective assistance so much sooner that the prognosis 
is somewhat better, although from the difficulty of securing asepsis 
unless the wound be below the cord proper — i. e. involving only the 
cauda equina — the outlook for life is most gloomy. 

Contusions of the membranes and cord, causing slight extra- or even intra- 
dural hemorrhages, are recoverable, but even when the osseous lesion is apparently 
limited to a spinous or transverse process "chronic inflammations and scleroses" 
may be expected to follow from slight concomitant lesions of the membranes or 
cord, which will result in neuralgias, impairment of function of the bladder, a 
limb, etc., but " which may not perhaps be manifested for years." 

Treatment. — Asepsis must be striven for and maintained, separated 
bone-fragments or the ball extracted, drainage be instituted, because 



GUNSHOT WOUNDS. 279 

asepsis is doubtful, and fixation of the spine should be effected. Where 
early symptoms of pressure on the cord suggest the probability that the 
ball, bone-fragments, or blood-clot is causing the paralysis, or, later, 
that exudate or callus is destroying function, a more or less formal lami- 
nectomy is indicated in cases not complicated by serious lesions else- 
where. 

Thorax. — Thoracic wounds may be non-penetrating or penetrating. 
The latter may be complicated by fractures of the ribs, sternum, verte- 
brae, clavicle, or scapula, and by wounds of the axillary and scapular 
vessels, many of these last proving rapidly fatal. Any apparent deflec- 
tion of modern balls from a straight line is due to the difference between 
the position when the wound was inflicted and when it is examined. Con- 
tusion of the pleura or lung, evidenced by shock, temporary dyspnoea, 
and pain during respiration, is not uncommon. 

Diagnosis. — From the small size of so many modern missiles, this 
is often difficult, neither protrusion of lung taking place nor inspiration 
and expiration of air occurring through the wound during the corre- 
sponding acts of respiration. Emphysema may occur in non-penetrating 
wounds from air insinuating itself among the tissues during the alter- 
nate expansions and contractions of the thoracic wall. If a line con- 
necting the wounds of entrance and exit would traverse a lung, such an 
injury may be confidently affirmed, as modern balls do not run for long 
distances beneath the thoracic soft parts. Pain, restriction of the free- 
dom of respiration, haemoptysis in varying amount, and cough accom- 
pany penetrating and perforating wounds of the lungs. Compression 
of the lung by accumulation of air or blood in the pleural cavity may be 
detected by the characteristic physical signs. Shock and collapse are 
usually greater than in non-penetrating wounds. External hemorrhage, 
when severe, comes from the cervical or axillary vessels. Internal 
bleeding comes from the intercostals, internal mammary, the large pul- 
monary vessels, the great vessels, or the heart. When from any of the 
three latter sources, the hemorrhage rapidly proves fatal. Bleeding 
from the lung-tissue is rarely of much moment. 

If a ball lodge — an unlikely accident in the future — it may remain harmlessly 
encapsulated for years, may ulcerate early or late into a bronchus and be coughed 
up, into the oesophagus and pass per anum, or pass into the pleural cavity. Even 
bone-fragments imbedded in the lung do not add materially to the danger, provided 
infection is prevented. 

Prognosis. — Asepsis has lessened the mortality of the past by 
diminishing the frequency of empyema, lung-abscess, and mediastinal 
abscesses, which formerly caused the high death-rate. The not uncom- 
monly associated wounds of the abdomen markedly increase the mor- 
tality. Prolonged intrathoracic suppurations may end in recovery, but 
with sequelae akin to those seen after the same conditions of non-trau- 
matic origin. 

Treatment.— Asepsis and immobilization of the chest, with treatment 
appropriate for any traumatic pleurisy or pneumonia, is all that is requi- 
site for non-penetrating wounds — i. e. those involving only the parietes 
— contusions or flesh-wounds. In penetrating and perforating wounds 
shock must be combated, and the ball should only be sought for if felt 
lodged in the chest-wall. Sterilization of the wound, must be effected, 



280 INJURY AND REPAIR. 

and after any bleeding has been arrested by ligature, forcipressure, or 
possibly tamponade, the thorax must be put at rest by strapping or a 
plaster-of-Paris jacket, Aspiration may be done for extensive hemo- 
thorax producing pressure, but this, as well as empyema, is better 
treated by excision of a portion of a rib to secure free drainage and 
the removal of any foreign bodies, as a bullet, fragments of bone, cloth- 
ing, etc. Concomitant fractures present the same indications as when 
occurring elsewhere. Pulmonary, intestinal, or omental hernia? through 
the lower intercostal spaces must be restrained by pressure. 

Heart. — Contusions, penetrations of the pericardium, penetrations and 
the slighter perforations of the heart-muscle alone come under treatment. 

Contusions result from nearly spent balls which retain enough momentum to 
tear the pericardium and then bruise the heart. Only a " tangential blow " can 
wound the pericardium alone. Lodgement without penetration, and penetration 
of one or more cavities with lodgement of a missile, will only follow pistol- or 
small-shot injuries. Concomitant lung-wounds are common. 

Prognosis. — Wounds of the base are usually promptly fatal, even 
when caused by small balls, but when resulting from the modern rifle- 
balls are invariably so from shock, or shock and hemorrhage combined. 
When the base escapes, temporary recovery, lasting for from days to 
years, sometimes occurs, bleeding being arrested by clot and contraction 
of muscular fibres until more permanent repair is effected. More com- 
monly death ensues within a short time from the accumulation of blood 
in the pericardium arresting the heart's action, rather than from actual 
loss of blood, although this may be profuse. After so-called recovery 
permanent damage of the organ remains. 

Diagnosis. — Any lesion of the heart produces the most profound 
shock — even fatal — with irregular action and modification of the hearts 
sounds — i. e. bruits. Increase in area of the dulness on percussion 
denotes bleeding into the pericardium. Pneumo-pericardium will cause 
a reversal of this symptom — diminution of dulness. 

Treatment. — Relief of shock, arrest of hemorrhage, asepsis, re- 
moval of the pressure of accumulations of blood and exudate in the peri- 
cardium by incision or aspiration comprise all the expedients usually 
available. Suture will hardly be feasible, however possible for an incised 
wound. 

Abdomen ; Solid and Hollow Viscera. — The parietes, especially 
in civil life, may be wounded without penetration of the cavity, 
although this is exceptional. Contusions, usually produced by contact 
with spent cannon-balls or blows from fragments of shell, often mean 
serious laceration of the viscera or rupture of the muscular parietes, 
possibly ending in gangrene of the abdominal wall. 

Prognosis. — In the absence of visceral lesions recovery should take 
place. 

Treatment. — Contusions require aseptic dressings for any abra- 
sions and early evacuation of pus and sloughs if these form. Flesh- 
wounds of the parietes require only that which is appropriate for sim- 
ilar wounds situated elsewhere. Laparotomy is requisite when visceral 
laceration exists. 

Penetrating and Perforating Wounds. — Although 3 to 5 per cent, of 
wounds pursuing an antero-posterior direction are free from visceral 



GUNSHOT WOUNDS. 281 

lesions, it is safer to consider that such complications exist, especially 
with wounds traversing the abdomen from side to side. The probable 
order of frequency of visceral injury is — small intestines; large intes- 
tines ; liver ; stomach ; kidney ; spleen ; pancreas. Usually multiple 
lesions exist, involving omentum, mesentery, lung — when the ball 
enters through or emerges from the thorax — or the large vessels, in 
addition to strictly visceral lesions. 

Prognosis. — This depends in each case upon the extent and nature 
of the lesions ; hence no specific statements as to prognosis can be made. 
The death-rate varies from 24 to 87 per cent., and results primarily 
from shock and hemorrhage, later from septic peritonitis. 

Diagnosis. — Protrusion of bowel, omentum, spleen, or the escape 
of bile or faeces render diagnosis easy, but such indications are rare 
even with the old-fashioned bullet of large calibre. In default of these 
signs exploration by incision of the ball-track or laparotomy can alone 
render penetration, much more visceral lesion, certain. The relation 
of the wounds of entrance and exit in complete perforations usually 
decides the question of visceral penetration. Vomiting or the passage 
of blood per anion or urethram, the physical signs indicating rapid 
accumulation of fluid — i. e. blood — in the belly, loss of liver-dulness 
from free air in the abdominal cavity, are, when all are present, positive 
signs of visceral lesions. Bloody vomit, stools, or urine might indicate 
mere contusion, but free peritoneal air can only mean bowel-wound, and 
rapid accumulation of intra-abdominal fluid, bleeding from omentum, 
mesentery, great vessels, or from a solid viscus. The hydrogen-gas test 
before laparotomy, when successful, will demonstrate intestinal wound, 
but its failure does not preclude the possibility of such an accident. 

Careful exploratory incision, opening up the wound-track, or in the 
median line when the wound is a transverse one, may be necessary, and 
is a safer diagnostic procedure than exploring with the probe or finger. 
The direction pursued by the ball, the point of entrance, shock, bloody 
urine, with the possible external escape of urine if the wound be situated 
in the back, will usually indicate a kidney-wound. 

Serious intra-abdominal lesions, according to Eedard, always produce a depres- 
sion of temperature for from four to many hours, and when such subnormal tem- 
perature is detected it is strong presumptive evidence of penetration with visceral 
wounding. Peritonitis, usually developed after the first eighteen hours, may show 
only slight rise of, or even depression of, temperature, but the pulse is usually 
notably frequent. In many cases, however, the ordinary complexus of symptoms 
indicative of peritonitis are present. 

Treatment. — This must be either purely medical, by opium, small 
amounts of fluid food, the ice-coil, and maintenance of local and general 
quiet ; or operative. The mortality with the expectant treatment, as 
given by numerous observers, varies from 59.4 to 65 per cent., the 
figures given by Reel us being so extraordinarily favorable as to throw 
suspicion upon their accuracy. The mortality after operation varies from 
66 per cent, to 78 per cent., but it must be remembered that the operated 
cases are usually those worst injured. 

Early operation, arresting bleeding and fecal extravasation or remov- 
ing this and draining, give the best results, success almost never attending 
section after development of generalized peritonitis. In military prac- 



282 INJURY AND REPAIR. 

tice it is rarely feasible to secure proper facilities in time to render a 
laparotomy successful, 

Technique. — If doubt exists as to penetration, determine this point 
by careful enlargement of the ball-track. This may settle the point 
where the abdomen should be opened, but a median incision is that 
which gives the best access to the organs most commonly injured. After 
having opened the abdomen, any bleeding should first be arrested by 
ligature, compressing the aorta as a temporary measure while the bleed- 
ing vessels are being exposed, or sterilized gauze packing may be em- 
ployed for the same purpose. The bleeding usually comes from the 
mesenteric vessels or from one of the solid viscera, although the intra- 
pelvic vessels, an intercostal or the internal mammary artery, may be 
its source. The small and large intestines must next be systematically 
examined, inch by inch, covering the protruded parts with towels or 
pads wrung out of hot sterilized salt solution, returning each loop as 
soon as examined. Every opening must be closed transversely, as 
detected, by fine silk Lembert sutures. Contused spots — as shown by 
Park — will slough, and must therefore be treated as if wounds. When 
closure of several closely contiguous wounds would constrict the lumen 
of the bowel too much, resection with end-to-end or lateral anastomosis 
must be done. Bents in the omentum should be closed, bleeding vessels 
ligated, and damaged omentum removed after tying off in sections. 
Wounds of the stomach, large intestine, urinary bladder, and solid viscera 
or gall-bladder must next be sought for, the three first being treated by 
suture, the last by suture or plugging with gauze. 

Inflation with hydrogen gas or air may aid in detecting intestinal wounds, hut 
is not infallible, fseces sometimes plugging the openings. Suture works best for 
liver- or kidney-wounds, plugging with gauze and drainage for those of the spleen 
and pancreas. Splenectomy and nephrectomy are only demanded for extensive 
lacerations. Repeated flushing of the abdomen with hot sterilized salt solution 
during and after the manipulations is advisable. Drainage must depend upon the 
amount of peritoneal fouling with faeces, urine, etc., the freedom from hemorrhage, 
and the probability of subsequent extravasations of urine from a wounded kidney 
or of bile from a damaged liver. 

The after-treatment consists in combating shock, careful alimentation, 
and, later, the draining off by the intestines of septic products by saline 
purgatives, differing in no material way from that adopted after other 
laparotomies involving intestinal lesions. Fecal fistula following wounds 
of the colon is a rare accident, and if spontaneous healing does not occur 
— a very common result — operative interference is indicated. Rectal 
wounds which are not part of other intra-abdominal lesions are chiefly 
of moment from the probability of widespread suppuration and slough- 
ing from infection. If the wound be below the peritoneal investment, 
it should be treated by disinfection of the wound and bowel, quiet of the 
latter induced by opium, and incisions for drainage if burrowing of pus 
occurs. Rectal wounds opening into the peritoneal cavity demand lapa- 
rotomy and suture, or possibly tamponade with drainage, if the wound 
for any reason cannot be sutured. 

Genito-urinary Apparatus. — Bladder-xvounds are often complicated 
with lesions of the pelvis, pelvic vessels, and rectum. An empty blad- 
der is seldom wounded. Partial penetration by guttering sometimes 
occurs, which usually soon becomes complete by ulceration. When the 



GUNSHOT WOUNDS. 283 

portion uncovered by peritoneum is wounded, the consequences are 
much less serious than when the peritoneum is involved. 

Prognosis. — This depends upon the associated lesions, especially 
opening of the peritoneal cavity. 

Symptoms. — Those pecular to Madder-wounds are irritability of the 
organ and possibly the rectum, hsematuria, and the escape of urine by 
the external wounds — a rare occurrence except after wounding with 
balls of the largest calibre. Hamaturia may also result from wounds 
of the urethra, ureter, or from simple contusion of the bladder. Mic- 
turition may or may not be possible, the latter symptom sometimes 
resulting from accumulation of blood-clot. Peritonitis rapidly super- 
venes if the peritoneal cavity is opened, and this may even arise by 
extension when the urine escapes into the perivesical cellular tissues, 
although this latter accident commonly only leads to abscess-formation. 

Treatment. — Abdominal section, suture of the bladder, and a care- 
ful peritoneal toilet are indicated, with drainage if deemed requisite. 

If reasonable doubt exists as to whether the peritoneum has or has not been 
opened, a suprapubic incision may be made, the prevesical space opened and drained 
after any vesical wound has been repaired. Advantage must be taken of the 
laparotomy or suprapubic wound to remove any ball, piece of bone, or clothing 
lodged in the bladder or elsewhere. Late cystotomy may be required to remove an 
undetected ball or pieces of bone which have primarily lodged in the bladder or 
found their way in by ulceration. Quiet, disinfection, and drainage of the wound- 
track, and prompt incisions to give egress to urine or pus, are requisite. Super- 
ficial wounds of the external genitals differ neither in danger nor treatment from 
similar ones produced by other traumatisms. Lodgement and even encapsulation 
of a ball have occurred. Marked laceration is the rule if the corpora cavernosa or 
glans penis are perforated : the urethra is usually also opened. 

Prognosis. — Cicatricial deformities, urethral stricture, and fistulse 
are not uncommon. 

Treatment. — Bleeding must be arrested by ligature, suture, or com- 
pression effected by firm bandaging of the organ after the introduction 
into the urethra of a metallic catheter. Antiseptic dressings are useful 
adjuncts. Any urethral wound must, when possible, be sutured, and 
the urine partially diverted by a retained catheter or completely by a 
perineal opening. When the whole organ has been shot away the 
corpus spongiosum must be dissected free and a perineal meatus estab- 
lished. Injuries of the testes, provided infection can be obviated, will 
usually do well, although atrophy or neuralgia are common sequelae. If 
completely disorganized, castration should be done. Wounds of the 
female genitals are exceedingly rare, and often involve the peritoneal 
cavity. Wounds of the pregnant uterus usually produce death by abor- 
tion, shock, hemorrhage, or infectious peritonitis. Fistidce giving exit 
to menstrual fluid have sometimes followed recovery after ball- wounds. 



CHAPTER XXIII. 

PROCESSES OF REPAIR. 

By Charles B. Nancjrede, M. D. 



Repair is effected by the same processes in the hard and the soft, the 
vascular and the avascular tissues, the differences being temporary, non- 
essential, and chiefly dependent upon physical conditions. Thus, the 
lime salts render the bone so dense that until they are removed only a 
limited accumulation of leucocytes and, later, proliferated tissue-cells, 
can take place at the site of injury ; yet from the outset the soft 
parts of the bone undergo the same changes, in kind, as does the least 
compact connective tissue. 

Two forms of repair are usually described, but in reality there is but 
one, the second variety being at the outset only a modification of the 
first, caused by disturbing influences : when these cease to be operative 
the processes of repair tend to proceed as at their inception, any varia- 
tions from the typical methods being accidental, not essential, parts of 
the process. In the normal method reparative processes commence from 
the moment the physical disturbance of the part ceases and the bleeding 
is checked. Here the minimum of reparative material is requisite, 
and the wound is said to heal by the first intention, by simple adhesion, 
or by aseptic inflammation (obsolete expression), because it is only possi- 
ble in the absence of infection. Where infection occurs the reparative 
processes are interferred with and thwarted, reverting eventually to those 
seen in the absence of suppuration, but vast quantities of reparative 
materials are wasted, unnecessary tissue-destruction results, and the sub- 
sequent changes in the excessively developed germinal tissue often cause 
serious interference with function. Healing is here said to have taken 
place by granulation or by the second intention, but the end-processes are 
the same in both forms. 

The following are the minute phenomena observed in the healing of an incised 
wound by primary union, or by the first intention. Hsemostasis is effected by 
thrombi occluding the vessels usually up to the first collateral branch. The blood, 
mingled with numerous leucocytes escaping from the divided lymphatics, provides 
elements for the formation of a coagulum (largely fibrinous), which extends for a 
short distance into the interstices of the tissues -on either side, mechanically unit- 
ing the wound. Later the union becomes a vital one by the formation of fibre- 
cells and blood-vessels bridging the gap and developing into scar-tissue. The 
borders of the wound soon become crowded with wandering cells, which rapidly 
invade the fibrinous clot and any blood-coagulum filling up the recesses of the 
wound. By the close of the third day a mass of leucocytes, separated by a scanty 
284 



PROCESSES OF REPAIR. 



285 



intercellular substance and scattered remains of the clot, has replaced the coagu- 
lum. About the sixth day large epithelioid cells, resulting from proliferation of 
the fixed connective-tissue cells and endothelial cells of the small vessels, appear, 
These are the formative cells, the fibroblasts, those capable of conversion into con- 
nective tissue. Most of the leucocytes serve as food for the new tissue-cells or 
wander back into the circulation by way of the lymphatics. Reinke believes that 
the lymphocytes which appear after proliferation of the fixed connective-tissue 
cells has commenced are of different nature from those first appearing, and are 
capable of development into tissue, while Eibbert teaches that they aid in tissue- 
formation by providing the lymph-s-.aces with endothelium. The fibroblasts, at 
first round, enlarge and assume spindle or club shapes, or develop one or more 
processes, even becoming branched : giant cells also form, which, with some of the 
fibroblasts, degenerate, become granular, and are absorbed. Anastomoses form 
between the cellular processes, and the cells themselves so increase in numbers 
that in some places they lie in contact. The fibrous portion of the forming scar- 
tissue has a twofold origin, developing partly from a homogeneous intercellular 
substance produced by the cells and partly from the protoplasm of the cells. The 
fibrillation commences on one or both sides of the cells or at one end, or, again, in 
one of the processes, the fibrils fusing with those of adjoining cells; the nuclei 
with some of the protoplasm form the fixed connective-tissue cells. 



Fig. SO. 







MPttmi' . ■ -mm 

Cicatrizing wound of liver, tenth day : a, young cicatricial tissue ; b, altered liver-tissue (Tillmanns). 

Examination of a young cicatrix shows numerous elongated cells, which, 

becoming still further converted into fibres, 
diminish in size until little but fibres can be 
detected. 

Rendering these changes possible is the 
nutriment supplied from the newly-formed 
vessels ; moreover, some of the fibroblasts are 
derived from the cells of the intima of the 
new vessels. At the outset the cells receive 
nourishment from the plasma coming from 
relatively distant vessels in the surrounding 
tissues by way of the plasma-channels. The 
first steps in new vessel-formation consist in 
an accumulation of granular protoplasm 
on the exterior of a pre-existing capillary 
loop which gradually forms a solid, nucleated 
filament. This may be simple or branched, 
and fuses with another vessel, with another 
bud from a neighboring capillary loop ; or, 
again, the filament may arch back and become 
connected with the vessel from which it 
sprang. The young connective-tissue cells 
(fibroblasts) near -the vascular outgrowths arrange themselves alongside them or as 
bundles form solid continuations ; again, they are said by some to form channels 
which later communicate with the lumen of some capillary: occasionally a proto- 
plasmic filament will join a process of one of the branched formative cells. These 
solid protoplasmic processes liquefy in their centres, a lumen forming continuous 




Healed wound of liver, twentv-eighth day ; 
blood-pigment in cicatrix still unabsorlx'd 
(Tillmanns). 



286 



INJURY AND REPAIR. 



Fig. 82. 



with that of the parent vessel. Sometimes the protoplasmic outgrowth is from the 
outset hollow, admitting blood, but even then it terminates by a filamentous pro- 
longation, and develops further after one of the methods already described. At 

first the new capillaries have homogeneous 
walls. Later they display nuclei, and finally 
present the ordinary endothelial structure, 
their walls becoming strengthened by apposi- 
tion of some of the neighboring tissue-cells. 
Most of the new vessels become obliterated by 
the condensation (contraction) of the newly- 
formed tissue, which accounts for the change 
of color in the scar from red to white. An 
aseptic wound with loss of substance may 
heal by " organization of blood-clot." This 
is merely an extension of the process by 
which trie interstices of any aseptic wound 
are obliterated when filled with blood-clot. 
The coagulum serves as a scaffolding, being 
first invaded by leucocytes and then by 
germinal cells. These latter subsist upon the 
leucocytes, the cell-mass becomes vascularized, 
and the usual conversion into scar-tissue takes 
place. The gradual removal of blood-clot 
by the pressure of granulations springing from 
the surrounding tissues, which is sometimes 
spoken of as organization of a clot, is a 
different process, the clot here being a me- 
chanical obstacle requiring removal, rather 
than an aid to healing. 

The so-called filling up of a wound by 
granulations is a misnomer. The organiza- 
tion of the deeper layers of the granulations 
into contracting scar-tissue draws down the 
wound-margins and lessens the superficial 
area. Microscopically, granulations consist 
superficially of numerous multi- and mono- 
nucleated leucocytes, with many delicate 
blood-vessels running more or less vertically 
to the surface. Deeper epithelioid cells 
abound, and still deeper spindle-cells ar- 
ranged in bundles can be seen, in old wounds 
having become distinctly fibrous tissue, with 
the blood-vessels forming a horizontal net- 
work. The classical capillary loops capped 
with cells, which are said to account for the 
granular form of the granulations, do not exist, parallel vessels, ascending more 
or less vertically, as has just been said, being alone detected. 

The foregoing statements include all the essential facts concerning 
the aseptic formation of granulations by which healing is effected in 
every tissue, although in certain highly specialized ones, as spinal nerves, 
regeneration of nerve-tubules takes place. Indeed, the end-processes 
are the same even when infection has occurred. Epithelial repair, 
covering the surface-defect, results from proliferation of the epithelium 
at the margins of the wound. Healing by granulations or by the second 
intention may pursue an aseptic or an infective course. The former 
occurs in wounds with loss of substance resulting from the original 
injury or from subsequent separation of dead tissue. Separation of 
devitalized tissue takes place without suppuration, the discharges are 
serous or lymph, cloudy from excess of leucocytes and young tissue-cells 
(not pus), and healing occurs with the minimum waste of material, dis- 




organization in blood-clot : o, fresh blood- 
clot ; b, leucocyte ; c, new capillary ; d, 
cross-section of a capillary ; e, young 
connective-tissue cells (Smith). 



PLATE XI. 







■-'-■ 



Granulation Tissue. 



a, Subcutaneous Fat; b, Proliferation froni Surrounding Skin; c, Granulation 
Layer; a', Fat Cells; a", Blood Vessel. (Klebs.) 



PROCESSES OF REPAIR. 287 

charge, and formation of contractile scar-tissue : the minute processes 
are the same which will be mentioned as those terminating the healing 
of a suppurating wound. When infection of a wound occurs any 
mechanical bond of union is broken down ; the scaffolding afforded by 
the uniting coagulum, by which the formative cells bridge the gap, is 
destroyed ; many of the newly-formed cells perish, peptonizing ferments 
dissolving the intercellular cement and separating the cells from their 
source of nutriment, while other toxic bacterial products directly attack 
the vitality of the cells. The infiltrated surfaces of the wound are also 
destroyed to a varying extent by the same agencies, and a proliferation 
of cells far in excess of the needs for repair takes place, many of these 
being lost in the discharges, many not receiving enough pabulum to 
develop properly ; but far too many survive to form dense cicatricial 
tissue. Where sloughing occurs the fragments of dead tissue provoke a 
livelv proliferation of the cells of the neighboring living tissues, so that 
finally the dead and living parts are only held together by a mass of 
cells. These are soon disassociated by death of some and solution of 
the intercellular cement by bacterial products, when the sloughs sep- 
arate, leaving usually far more granulation-tissue and consequent con- 
tracting scar than is produced by mere prolongation of suppuration 
without sloughing. The end-processes of this suppurative granulating 
process are the same as those already studied under aseptic union by 
the first intention. The same conversion of cells into fibres, the same 
method of vascularization, an identical but greater condensation (con- 
traction) of the deeper layers of the healing granulating surface, reducing 
its superficial area, occur. ( Vide Plate XL) 

Epidermization is effected by proliferation of the epithelium of the 
wound-margins, the remains of the Malpighian layer of the skin or the 
sebaceous and sweat-glands when the skin has escaped total destruction. 
In healing by either variety of second intention only a comparatively 
limited formation of new epithelium is requisite, because, as just seen, 
the defect to be covered is very materially lessened by contraction of 
the granulation-tissue. The last small area of granulations — and this 
is true of the end of any method of healing — may become covered by a 
dried crust of exudate, beneath which the epithelial cells form : when 
healing is completed the crust drops off. This is heeding by scabbing 
or under a scab, and is a desirable method to attempt under appro- 
priate circumstances. Two aseptic granulating surfaces, if maintained 
in contact, will often fuse together, healing then being said to occur 
by the third intention or secondary aelhesion. Upon this fact depends 
the success of many cases of secondary suturing. The vitality of 
skin-grafts (not epidermic) of a severed nose or a finger-tip is main- 
tained, according to Thiersch and Tillmanns, by direct communications 
formed between the vessels of the granulations and those of the graft 
or severed part through the medium of the intercellular plasma-chan- 
nels. Later, all the phenomena described as pertaining to union by first 
intention (primary adhesion) occur. The transplanted part is passive 
until after the third day, when it commences to become vascularized. 
Despite the two or more days' interruption of direct blood-supply, only 
the epidermal layer, a portion of the rete Malpighii, and most of the 
vessels perish, the latter by atrophy and hyaline degeneration. In from 



288 INJURY AND REPAIR. 

three to four days the epithelial cells of the sebaceous and glandular 
follicles proliferate and penetrate the mass of newly-formed cells, and 
in two weeks, according to Garr6, the conversion of granulations into 
connective tissue is completed. 

A few words as to repair in non-vascular tissues, as cornea and car- 
tilage. In the former its anastomosing intercellular plasma-channels 
readily admit wandering cells coming from the vessels of the related 
vascular structures (sclera and conjunctiva), and later proliferation of 
the fixed cells and vascularization occur. The same remarks hold good 
for cartilage, except that the scar is alleged to remain fibrous for a long 
time if aseptic healing has occurred, while " if a severe inflammatory 
reaction takes place the cicatrix will rapidly become hyaline, like normal 
hyaline cartilage." 

Regeneration of Tissues. — In only a few tissues does repair pro- 
ceed beyond the formation of scar-tissue. Where regeneration is pos- 
sible its perfection will be in proportion to the apposition effected and 
the asepsis secured. Surface epithelium and all connective-tissue struc- 
tures, as fasciae, bone, or tendons, can be completely regenerated. 

Epidermis. — This, including the epithelium of the intestinal tract, 
is completely re-formed, the new cells being descendants of pre-existing 
epithelial cells found at the margin of the wound, or, after partial 
destruction of the skin, originating by division of the epithelium of 
various cutaneous glandular structures whose extremities lie in the 
deeper portions of the skin or actually in the cellular tissue beneath. 

Skin. — Regeneration of the fibrous portion is complete, although the 
arrangement of the bundles is more irregular, and it is long before elas- 
tic tissue is developed in the scar, but the hair, sebaceous and s-weat-fol- 
licles, with the true rete Malpighii, are not re-formed. Lymphatics are 
also absent, and an old scar is so much less vascular than normal skin, 
from obliteration of most of its vessels, that it is liable to break down 
from slight causes. 

Fasciae, Tendinous Sheaths, and Tendons. — Repair in these tissues 
amounts practically to regeneration. After division of a tendon the 
proximal end retracts, and the method of repair varies somewhat 
according to the presence or absence of blood-clot. In the rabbit, when 
but little blood is effused emigration of leucocytes occurs, followed in 
from two to three days by rapid proliferation of the cells of the sheath. 
Many of the cells of the tendon-stumps rapidly degenerate, but about 
the fourth or fifth day some take part in the formation of the granula- 
tion-tissue. The exudate extends some distance above and below the 
extremities of the softened, succulent, and newly- vascularized tendon. 

Muscles. — Muscular defects are only repaired by scar-tissue forming 
from the connective tissue and endothelial elements. Near the cicatrix 
or after slight injuries and contusions regeneration is observed to a limited 
extent — according to one view, commencing by enlargement and prolif- 
eration of the muscular nuclei, resulting in the formation of large mono- 
and polynucleated cells, occupying the place of the destroyed fibres. 
These develop into spindle-cells lying side by side, which soon become 
longitudinally fibrillated and show commencing transverse striation dur- 
ing the third week. According to another view, granulation-tissue first 
forms among and around the necrosed muscle-fragments. The ends of 



PROCESSES OF REPAIR. 289 

the damaged muscle-cells break up into spindle-shaped fragments which 
undergo fatty degeneration preliminary to absorption. The nuclei of 
the living muscle-cells proliferate, forming bundles of muscular cells 
near the injured area which totally disappear by the third week. The 
disappearing fibre is replaced by a bundle of longitudinally striated fibres 
and spindle-cells formed by splitting up of the muscle-fibres and prolif- 
eration of the nuclei. Growth of muscle-fibres into the granulation- 
tissue and disappearing mass of muscular debris commences about the 
sixth day by small, multinucleated protoplasmic fibres springing from 
the stumps of non-degenerated fibres or from those longitudinally split. 
These outgrowths may be bifurcate, with club-shaped or fusiform extrem- 
ities which contain many nuclei. Longitudinal striation occurs early, 
followed at the close of the second week by transverse striation. The 
new muscular filaments interlace, lateral budding being not uncommon. 
The fibres gradually increase in bulk and become striated transversely, 
but many fail to develop and soon disappear by fatty degeneration, those 
which remain interlacing with others from the opposite side of the gap 
until the connective-tissue scar in very slight wounds may disappear. 
Much of the interlacing disposition of the fibres is gradually replaced 
by a normal arrangement, but some irregularity always remains. 

Blood-vessels. — Vascular repair depends upon the formation and 
so-called organization of thrombi — i. e. the formation of vascular cica- 
trices. Injury to or destruction of the endothelium and partial or com- 
plete arrest of the blood-current are requisite. 

Once formed, the thrombus may organize, may calcify, or may soften. 
The minute processes are as follows : The vascular wall first and the 
thrombus next become infiltrated with leucocytes, which seem to pene- 
trate the latter by many routes, thus breaking it up into isolated masses. 
The endothelium proliferates where injured, and the thrombus gradually 
becomes replaced by formative cells thence derived, which penetrate 
along the tracks prepared by the previous invasion of leucocytes. Vas- 
cularization and subsequent development of the germinal tissue is effected, 
all traces of the thrombus being removed. The organization will be 
slower when the thrombus does not entirely occlude the vessel, because 
the formative cells can only enter through those portions in contact with 
the vessel-wall. One or more of the new vessels may persist or enlarge, 
restoring in a measure the continuity of the vascular lumen, but usually 
the occluded segment of vessel shrinks into a fibrous cord. 

Nerves. — Under favorable circumstances repair is here complete. 
The alleged immediate union of nerves with restoration of their con- 
ducting power, with no degeneration of the peripheral end occurring, 
appears to have been established clinically, but experiments upon ani- 
mals negative this view, while anastomoses between nerves, supplemental 
or vicarious sensibility, and differences in the distribution of a given 
nerve probably explain the so-called primary union. Degeneration of 
the whole of the distal with a portion of the proximal end is the rule, 
repair taking place chiefly by growth downward of embryonic fibres, 
originating from pre-existing fibrils : these penetrate the granulation- 
tissue by which the physical union of the trunk is effected. According 
to Howell and Huber's experiments upon the dog, in four days after 
section the myeline sheath becomes segmented and the axis-cylinder is 
10 



290 INJURY AND REPAIR. 

fragmented in the peripheral portion of the nerve. By the seventh day 
active nuclear proliferation has begun in the neurilemma, with migration 
of the new cells, several often occupying one internodal space. During 
the next week the segmented myeline and fragmented axis-cylinder 
disappears by absorption, complete removal being effected in fourteen 
days. Next the nuclei acquire an investment of protoplasm, which 
increases until a single solid protoplasmic fibre with imbedded nuclei 
occupies the old sheath. " When union is made with the central end 
this is the rule, but if this does not take place, one or more fibres may 
arise within an old sheath by longitudinal cleavage." These amyelinic 
embryonic fibres later acquire a myeline sheath, the old sheath probably 
becoming part of the endoneural connective tissue. Return of function 
in the dog commences about the twenty-first day and is complete in 
eighty days. 

Bone. — The union may be immediate or by second intention — i, e. by 
granulation, the bond being usually genuine osseous tissue. Examining 
a fracture of a long bone, considerable blood will be found effused from 
the ruptured medullary and Haversian vessels as well as from those of 
the periosteum and contiguous soft parts which have been lacerated. 
Even in the rare event of the periosteum not having been torn, it is 
more or less stripped off the broken extremities. The injured tissues, 
infiltrated with blood, are soon invaded by leucocytes and exuded blood- 
plasma, and, fibrinous coagulation occurring, the extremities of the 
broken bone lie imbedded in a dense, ill-defined mass of firm cellular 
exudate involving periosteum, connective tissue, and possibly environing 
muscle. The blood entirely disappears by absorption in from fourteen 
to twenty-one days, when the firmer cellular exudate (callus) is seen to 
be a dense tissue, most abundant in and beneath the periosteum and 
extending between the ends of the fragments : in some parts the callus 
is cartilaginous. In from seven to fourteen days longer the soft callus 
ossifies, forming a spindle-shaped ferrule of porous bone (provided the 
fragments have not been much displaced). Meanwhile similar changes 
have also been taking place in the medullary tissues — viz. the blood-clot 
has been with the neighboring soft parts of the medulla infiltrated with 
leucocytes, the blood is next absorbed, the fat disappears as the connec- 
tive and endothelial cells proliferate, and granulation-tissue forms from 
both bone-fragments, which soon fuses and develops into porous bone 
blocking the medullary canal. Much later the connective and vascular 
tissues occupying the Haversian canals in the compact bony tissue con- 
tiguous to the fracture proliferate, the lime salts gradually disappear, 
and the granulation-tissue thus formed is converted into bone, definitely 
uniting the fragments. When union has been finally completed the 
excess of external and internal callus is absorbed, the medullary canal 
is restored, and in time the site of the fracture may be hard to detect if 
the reduction has been perfect. When overlapping occurs, the open 
ends of the medullary canal become closed off by bone, and its lumen 
is usually only imperfectly restored by gradual conversion of the over- 
lapping and fused portions of cortical bone into cancellous bone. 

Ossification usually starts in the angles formed between the separated 
periosteum and bone, and extending thence, the two buttresses meet and 
fuse at the middle of the spindle-shaped mass of provisional callus. Bone 



PROCESSES OF REPAIR. 291 

callus, as the tissue is now termed, is formed of a network of trabecule, 
the interstices of which are occupied by masses of young cells which 
have not yet ossified : the peripheral layer of these masses, however, are 
steadily being converted, layer by layer, into bone. Most of the hyaline 
cartilage sometimes found in callus disappears before the advancing 
ingrowths containing osteoblasts, but some is directly converted into 
bone by deposition of lime salts in the matrix, a portion of the cells 
remaining as bone-cells. 

Similar changes occur in the medullary canal, the osteoid tissue com- 
mencing at the periphery of the canal and spreading thence concentri- 
cally until its occlusion is effected. Hyaline cartilage is rarely seen in 
this internal callus. Finally, the Haversian canals of the compact tissue 
of the ends of the fragments become choked with a round-celled infil- 
trate ; the lime salts are dissolved and removed with the ground sub- 
stance, large cancellous-like spaces thus resulting filled with young 
osteogenetic cells. The germinal tissue thus formed on the ends of the 
fragments with the contiguous portions of the cellular exudate compos- 
ing the internal and external callus fuse, and union of the cortical bone 
takes place by ossification of this definitive callus. 

Healing of bone by the second intention — i. e. by granulation — takes 
place in open fractures where either loss of bone or death of bone 
occurs. In the first place, the periosteum having usually been destroyed 
over the osseous defect, the cells of all the soft tissues of the neighbor- 
ing bone proliferate, forming the granulation-tissue, which, as the super- 
ficial parts close over and cicatrize, becomes converted into bone by one 
or more of the methods described. When necrosis occurs, at the border- 
line between the dead and living parts lively proliferation of the cells 
of the periosteum, medulla, and Haversian canals produces a mass of 
germinal tissue, some of the cells (osteoclasts) causing absorption of the 
bone-substance until the continuity of the dead and living bone is 
interrupted by a layer of cells. In suppurating wounds the bacterial 
peptonizing ferments effect the solution of the intercellular cement, thus 
detaching the dead fragment, but in aseptic wounds a similar result 
follows from a more gradual loss of vitality, disintegration, and solution 
of cells and cement. When the dead bone is removed the granulations 
go on to cicatrization — i. e. ossification. 



CHAPTER XXIV. 

TREATMENT OP WOUNDS : ANTISEPSIS AND ASEPSIS. 

By Charles B. Nancrede, M. D. 

In this last decade of the nineteenth century it would seem needless 
to do more than state the fact that modern surgery only became a possi- 
bility since Listerism — i. c. the principles of wound-treatment first 
enunciated by Lister — has become the rule in practice. 

Although the injection of a number of irritant germ-free substances 
may initiate the formation of a puruloid fluid, this fact really has no 
bearing upon wound-treatment, since we are never confronted with such 
conditions clinically, and the resultant fluid is innocuous when injected 
into another animal. Again, the injection of culture-media or pus, in 
which the germs have been destroyed, merely produces the condition 
resulting from the action of living germs — viz. the presence of toxines 
and ptomaines, which are the active agents in the production of pus. 

In practice, then, all pus and interference with normal wound-pro- 
cesses result from the presence of pathogenic organisms, for all germs 
are not harmful. To effect their exclusion or destruction it is requisite 
to understand the sources whence derived and the conditions favoring 
their development. They are present in the air, in water, in dust, and 
in the soil, and of course in pathogenic wound -discharges. 

While it is true that if a wound is germ-free nature's reparative 
processes will pursue an uninterrupted course, it is also true that germs 
may be present and yet no harm ensue. The healthy blood and tissues 
destroy or remove germs, so that unless they are present in large num- 
bers or the vitality of the tissues be lowered, no disturbance results and 
the germs promptly disappear. The more vascular tissues seem to possess 
the highest degree of immunity, as seen in wounds of the face. The 
absence or scarcity of pabulum produces similar results, as shown by 
Grawitz's experiments, where the introduction of sterilized fluid indu- 
cing a serous exudation determined a peritonitis after inoculation with 
pyogenic organisms, pabulum being present, because the peritoneum 
could not remove rapidly enough that which the germs fed upon and 
multiplied in. In the absence of the serous exudate relatively large 
quantities of pyogenic organisms could be introduced with impunity. 
Again, slight traumatisms of the peritoneum by lowering the vitality of 
the tissues at such points enabled the germs to gain a foothold, multiply, 
and initiate a spreading peritonitis. 

These facts teach a twofold lesson : (1) that fluids that serve as germ- 
food should not be allowed to accumulate in wounds, and (2) that all 
unnecessary damage to the tissues must be avoided, because it diminishes 
their germ-inhibitory and destructive power. 

292 



TREATMENT OF WOUNDS, ETC. 293 

ASEPTIC SURGERY. 

Two courses are open to the surgeon when operating or in the treat- 
ment of accidental wounds. He may remove, inhibit the growth of, or 
destroy all germs upon his own hands, those of his assistants, his instru- 
ments, sponges, the part to be operated upon, and in the dressings, 
nothing but that which is aseptic — /. e. germ-free — coming into contact 
with wounded surfaces. With proper precautions this germ-free condi- 
tion persists, healing occurring with the minimum of disturbance. To 
this method the term aseptic is applied, the ideal outcome of Lister's 
work. 

Owing to the impossibility of certainly excluding all germs or germs 
in harmful numbers, as in certain operations within the mouth, rectum, 
or in accidental wounds, measures must be adopted calculated to inhibit 
the growth of, or destroy when possible, all micro-organisms which 
have gained access to the wound, and to further prevent their subse- 
quent multiplication in the dressings, whence secondary infection of the 
wound might result. Wound-treatment conducted according to these 
principles is termed antiseptic and is the original plan advocated by 
Lister. As many of the measures employed in this latter method are 
requisite preliminaries rendering possible aseptic operating, they must 
be considered. 

Disinfection, or Sterilization (Germ-destruction), and Disinfecting 
or Sterilizing Agents (Germ-destroying or Inhibiting Agents). — Koch 
and his followers have demonstrated beyond cavil that heat, and heat 
alone, is universally germicidal, but while this is a fact, certain inherent 
difficulties confront us in practice. Much difference in results follows 
the method of employing heat. Thus contact with boiling water for 
one to five seconds will destroy the adult forms of any pathogenic micro- 
organisms, and the spores even of anthrax in two minutes. Steam may 
be used superheated — i. e. under pressure — or simple " live," actively 
generated, and freely-escaping steam. In this latter form it will destroy 
anthrax-spores in from ten to fifteen minutes. It must be remembered 
that spores are vastly more resistant than adult micro-organisms, and 
that all varieties of pathogenic micro-organisms succumb with ease as 
compared to the anthrax bacillus. A too common mistake is made in 
forgetting that while a limited period only is required for the action of 
any efficient degree of heat, it must be that degree of heat applied directly 
to each spore or adult germ. Hence even boiling water requires longer 
time to be germicidal, than in laboratory experiments, when employed 
for bulky, tightly-folded, or wrapped dressings, or when, as is often 
true, germs are included in masses of coagulated pus, blood, or mechan- 
ical filth. This fact is of still more importance when steam is employed. 
All dressing materials and instruments must be, as far as possible, 
mechanically cleansed and then so arranged that the steam readily gains 
access to all parts, especially the interior of dressings. 

With the now general introduction of formalin (formaldehyde) we 
have learned that it is perhaps the most valuable of all adjuncts to 
sterilization. Its bactericidal properties are so powerful, and its injurious 
effects upon instruments and materials so trifling, that it appears at once 
as the ideal agent for this purpose. There are now to be procured from 



294 INJURY AND EEPAIR. 

the retailers so called paraform tablets, one or two of which when heated 
in any closed receptacle of simple construction will give off enough 
formaldehyde vapor to sterilize everything which the surgeon needs thus 
to protect. Catheters, especially, may be mentioned as being difficult 
ordinarily to sterilize, yet they may be made absolutely harmless by 
this method. 

It is folly to put tightly-folded, cold towels into any sterilizer for the mini- 
mum time employed in the laboratory to destroy pyogenic organisms, and then 
expect aseptic results. Hot air is the least efficient method of employing heat, 
because of the higher temperature and longer period of exposure requisite and its 
feeble power of penetration. Anthrax-spores, none of which survive after two 
minutes' contact with boiling water or fifteen minutes' exposure to " live " steam, 
require three hours' dry heat at 140° C. to produce the same effect, and much 
longer exposure when occupying the interior of dressings, folded clothing, etc. 

Confusion of the essential differences between the germ-inhibiting 
action of chemical substances and between their action in the presence 
of living tissues and the wound-fluids is answerable for much of the 
past and some of the present theoretical and practical disbelief in asepsis 
and antisepsis. Nearly every agent we employ in the strength in which 
it actually reaches the germ is not germicidal, but does usually prevent 
the growth of micro-organisms to any harmful extent. Let the most 
thorough mechanical cleansing and chemical disinfection of the skin be 
employed, such as will presently be described, yet in most instances the 
chemical precipitation of the alleged germicide, say mercuric chloride, 
will demonstrate by culture-experiments that germs in harmful num- 
bers are present, although incapable under ordinary circumstances of 
producing evil. It is not denied that when concentrated some of the 
chemicals ordinarily employed will destroy either at once or in a short 
time adult germs or even the resistent anthrax-spores, but in the 
strength possible safely to employ in a wound they inhibit only ; hence 
the great importance of their mechanical removal and exclusion and 
conservation of tissue-resistance, because under certain circumstances 
chemical inhibition may fail. 

The last means of sterilization to be considered, although of the 
most importance so far as the surgeon's and assistant's hands and the 
field of operation are concerned, is the mechanical removal of extraneous 
dirt, accumulated epithelium and, germs, and the superficial epidermic lay- 
ers in which at least one pyogenic micro-organism has its normal hab- 
itat. By the same means much of the oily matter abounding in the 
skin is removed, but when extra precautions are requisite certain sub- 
stances especially adapted for the removal of fatty materials should also 
be employed. 

Mechanical Sterilization. 

The preparation of the surgeon's, assistant's, and nurse's hands will 
first be described. Sterilized water as hot as can be borne should be 
employed. This must, of course, be never cooled by the addition of 
any but cold sterilized water. In hospital practice this water is always 
to be removed from the vessel in which it is sterilized by heat at the time 
when about to be used. In private practice, after thorough boiling, the 
water, previously filtered when necessary, may be placed in sterilized 
vessels protected from atmospheric dust — i. e. that containing germs — 



TREATMENT OF WOUNDS, ETC. 295 

by a sterilized towel. Special care must be exercised that the cup or 
dipper used to transfer the water from the vessel — oftentimes a wash- 
boiler or large tin dish — is always replaced in the boiling water to main- 
tain its asepsis. The nail-brush, best made of vegetable fibre, must be 
always carefully rinsed after use and be sterilized by heat for each ope- 
ration. The heat employed may be live steam for fifteen to twenty 
minutes or boiling in water for five minutes. Although it is alleged 
that all soaps made by heat are sterile— indeed, that potash soap is an 
active germ-inhibitor in the proportion of 1 : 5000 — yet it is the part of 
prudence to combine with the soft soap 5 per cent, hydronaphthol or 
thymol to ensure that the soap itself is free from germs. After thor- 
oughly rubbing in the hands and arms and under the nails abundance 
of soap, the nail-brush and hot water must be vigorously used, especi- 
ally beneath and around the nails, for from two to five minutes. Next 
carefully clean the nails and around them with a nail-cleaner. Removal 
of all grease can now be effected by ether or by immersion in alcohol, 
or best by alcohol containing 5 per cent, of dilute acetic acid, which 
should be rinsed off thoroughly with sterilized water, removing the last 
traces of soap. Finally, the hands should be immersed — not merely 
dipped — in a 1 : 2000 mercuric solution, for not less than three — prefera- 
bly five: — minutes. Instead of corrosive-sublimate solution, ordinary 
mustard flour mixed in the hands into a thin paste with sterilized water, 
used with gentle friction for two or three minutes and then removed 
with sterilized water, will prove a most successful germicide (Park). 

Sterilization of the Field of Operation. — The same principles are 
applicable and almost identically the same measures are to be employed. 
When the patient's condition permits, a general warm bath should be 
taken, after which recently laundried clothing should be donned. Care- 
ful shaving should precede all operations. Next should follow prolonged 
but gentle scrubbing with nail-brush, hot water, and soft soap, especial 
attention being paid to such parts as the axilla, pubes, and umbilicus. 
All grease left must be removed by free bathing and rubbing with alco- 
hol and acetic acid. Finally, a careful scrubbing with 1 : 2000 mercuric- 
chloride solution — or mustard flour used as already indicated — should be 
done, and the parts covered with a dressing wet with the same solution 
or one of 2\ per cent, carbolic acid, the latter being especially applicable 
where much oily matter is to be met with, as the scalp or axilla. This 
dressing should only be removed after anaesthesia has been induced, when 
the parts should be again cleansed with a germicidal solution, which then 
can be removed by free ablutions with sterilized water. 

Vagina. — Mechanical cleansing is here our mainstay. Abundance of 
soft soap on a vaginal mop made of sterilized cotton or gauze or a long 
soft jeweller's brush should be employed to scrub the vagina, free irri- 
gation with sterilized water being employed while doing this. 

Intestines and Rectum. — Thorough purgation and liquid diet must be 
employed, the former being sometimes properly secured in tight rectal 
strictures by a previous inguinal colotomy. Free and repeated lavage 
of the colon with sterilized water in the "knee-elbow" position is indi- 
cated shortly before operation. 

The object in view when preparing the field of operation thus far has 
been the prevention of contamination of the deeper parts by germs 



296 INJURY AND REPAIR. 

derived from without or resident upon or in the integument or mucous 
membrane. While not, strictly considered, preparation of the field of 
operation, the special measures adapted to prevent infection by pus or 
secretions of the peritoneum, cerebral membranes, pleura, pericardium, 
and healthy bladder can best be considered in a general way here, refer- 
ring the reader to the proper sections of this work for details. 

Stomach. — When fecal vomiting exists from any cause or preceding 
gastrostomy, gastrectomy, gastroenterostomy, gastrotomy, etc., gastric 
lavage should be done with Thiersch's solution or the normal salt solu- 
tion, the latter being usually abundantly sufficient. Peritoneal infection 
must further be guarded against by suture of the stomach to the parietal 
peritoneum (gastrostomy) before incising the viscus, or after bringing 
the organ as far as possible into the parietal wound by careful walling 
off by packing with sterilized or iodoform gauze. 

Accidental Operative Wounds of the Pleura, Pericardium, and Peri- 
toneum. — If the conditions are favorable, immediate suture is preferable, 
but if subsequent manipulations might open again the wound, tempo- 
rary gauze packing must be done. This may be removed and the wound 
sutured at the close of the operation, or a clean packing allowed to 
remain to induce limiting adhesions, aid in disinfection, and serve as a 
drain if the serous membrane has certainly or probably been infected 
during the operation. 

Bladder. — Although the introduction of a few pathogenic germs into 
a healthy organ may prove harmless, owing to their prompt removal 
with the urine, they may produce the most disastrous results. An 
already diseased viscus containing a stone or tumor is what the surgeon 
usually has to deal with, and here the introduction of streptococci or 
staphylococci — the usual causes of cystitis — is certain to give rise to 
trouble. As operations involving the bladder demand in nearly every 
instance the introduction of instruments per urethram, an antecedent 
aseptic condition of this canal must be secured. Normally, the urethra 
is alleged to harbor many germs which if carried into the bladder can 
originate a cystitis. Most careful lavage of the urethra must be per- 
formed, when possible, by a retro-acting deep urethral catheter, using 
sterilized salt, boro-salicylic, or bichloride solution according to the con- 
dition present. 

If urethritis be present, any introduction of instruments is to be deprecated, 
and when unavoidable a most careful employment of the measures is indicated. 
Urethral first, and then vesical, lavage must precede all operations upon the 
bladder except where impassable structure exists. As soon as any such impedi- 
ment is overcome most thorough washing out of the bladder and urethra should 
follow or be used during the operation — first with an antiseptic solution, then 
abundance of sterilized salt solution. The internal use of salol, quinine, or boracic 
acid for a few days previous to operation often markedly changes the character of 
unhealthy urine, and is imperative when the upper urinary passages or kidneys are 
involved iu the infective process. Salol must not be exhibited for a lengthened 
period, owing to its noxious action upon the kidneys. 

Antiseptic Surgery. 

This aims to remove, destroy, or neutralize the noxious effects of germs 
which have gained lodgement in the tissues. Heat, when applicable in 
the form of the cautery, is most efficacious, directly destroying the germs 



TREATMENT OF WOUNDS, ETC. 297 

and the tissues in which they reside, converting these into an aseptic 
eschar, which must separate by processes which commonly leave a layer 
of healthy granulations usually competent to bar the further ingress of 
germs. .Chancroids, lupus, tubercular and such spreading processes as 
hospital gangrene, are amenable to this treatment. Except when em- 
ployed as potential cauteries, chemical substances cannot be used in suf- 
ficient concentration to destroy all germ-life in an infective process. 
Hospital gangrene and some few analogous conditions have, it is true, 
been successfully combated with pure bromine, carbolic, and chromic and 
fuming nitric acid, and strong solutions of chloride of zinc, but these 
must destroy, as the hot iron does, all the infected tissues, otherwise after 
a period of quiescence the disease will break out anew. Many of these 
and other substances employed, as corrosive-sublimate paste, are poisonous 
if applied to large areas. Most usually, disinfection by lotions is limited 
to the superficial portions of the infected area. Removal of all infected 
tissues by excision — when limited by curetting or dissection with knife 
or scissors — is most efficacious, as in some carbuncles or in anthrax. 
When complete mechanical removal is impossible partial excision may 
be supplemented by the actual cautery, as is often done in anthrax. 
Incisions by relieving tension, giving exit to discharges and sloughs, me- 
chanically remove many germs and toxines, besides rendering possible 
the access of germ-inhibitory substances. Irrigation with a powerful 
stream is an important mechanical adjuvant to incision, but distention 
of the cavity must never be permitted, two tubes being employed or a 
counter-incision made. Rough handling must also be avoided, as calcu- 
lated to rupture granulations or the tissues and thus open up new ave- 
nues for infection. An exception to this rule is often presented by certain 
ischio-rectal abscesses, where the cavity should be made a simple one by 
breaking down the irregular partitions. 

Peroxide of hydrogen is useful to disinfect irregular cavities when not 
too large. Tubes are preferable to packing in all cases where it is not 
certain that all infection has been removed, because the solid portions of 
pus cannot be removed by capillary action ; but packing to secure the 
prolonged contact of iodoform with sloughs or infected tissues, because 
of its germ-inhibitory and toxine-destroying property and to prevent 
re-infection, is often useful and may be combined with tube-drainage. 
When the discharge becomes serous and small in amount, drainage can be 
dispensed with, but gradual shortening of the tubes and lessening of the 
quantity of packing at each dressing must precede this until the cavity 
becomes nearly effaced. 

Drainage. — Many aseptic operations require no drainage. Increas- 
ing experience and improved technique lead each surgeon gradually to 
discard it. In some form it becomes necessary — (1) when much bloody 
serum will be poured out; (2) where cavities must be left ; (3) where per- 
fect asepsis or its maintenance is doubtful; (4) where infection has occurred. 

Drainage may be direct — i. e. where discharges are removed by tubes, 
etc. ; or indirect — i. e. by leaving a part or the whole of a wound open ; 
packing or employing secondary suture ; by buried sutures, compresses, 
bandages, etc., so disposed as to leave no cavities in which fluids can collect. 

Direct drainage is tubular or capillary. Well-annealed glass tubes 
with lateral openings are best when of the proper length, because non- 



298 INJURY AND REPAIR. 

collapsible and readily sterilized by boiling. Rubber tubes are more 
commonly employed because capable of being used of any length. 

Capillar}/ drainage is only adapted to the removal of blood or serum, 
and must never be used for pus. A strip of gauze protruding from an 
angle of a wound is sometimes employed. Sterilised horsehair or fine 
catgut is the usual material. Certain precautions must be observed. 

Sterilization of Instruments, Ligatures, Sponges, and 

Dressings. 

Instruments. — All instruments should be entirely metallic, with 
smooth plane or simply curved surfaces. If complex, they must be 
readily separable into their component parts to permit mechanical 
cleansing. Wooden or ivory handles are damaged by heat, and from 
the inequalities of their surfaces are hard to cleanse mechanically ; still, 
they can be sterilized by the exercise of care. Aluminum being attacked 
by alkaline fluids is therefore undesirable. Too much stress has been 
laid upon the receptacles in which instruments are stored. It is de- 
manded that they be constructed of enamelled iron and glass tightly 
closing to exclude dust. Even the pocket-case must be metallic or made 
of canvas, so that it can be frequently sterilized. While desirable, 
these are unnecessary refinements, deluding to those not thoroughly 
versed in aseptic principles, because the asepsis is only relative and ig- 
nored by the expert, because he never trusts to such inadequate pre- 
cautions, but specially sterilises his instruments for each operation. 

Chemical disinfection of instruments has long been abandoned in 
favor of heat, except to meet special indications, because of its unre- 
liability and the injurious effects exerted upon instruments, destroying 
the cutting edge and polish and interfering with the smoothness of 
working if complicated. Dry heat, being tedious in its application, 
injurious to temper unless skilfully employed, and requiring cumber- 
some apparatus, is rarely employed. Many surgeons prefer in hospital 
work "live" steam, the water from which it is generated being charged 
with 1 per cent, of washing soda. This prevents rusting and adds to 
the germicidal powers. From five to ten minutes' exposure will kill 
any pyogenic organisms, since twelve minutes will destroy anthrax- 
spores. More than ten minutes may be advantageously employed to 
insure the best results. 

In private practice boiling water containing 1 per cent, of soda is more rapid 
and convenient than steam, any vessel large enough to contain the instruments 
serving to boil them in. Pure cultures of the pyogenic organisms will succumb in 
the boiling soda solution in from two to three seconds, and anthrax-spores in two 
minutes. 

While the sterilization of metallic bougies and catheters by heat or 
boiling presents no difficulties, it is far otherwise with the elastic 
(English), the soft (French), and the pure rubber (Nelaton) instruments. 
If oily substances be used as lubricants for these soft instruments, they 
should be soaked for a short time in warm (not hot) solution of washing 
soda previous to sterilization. If glycerin is employed, simple sterilized 
water will suffice. Formalin, as already mentioned, constitutes the best 
agent for all these rubber instruments. 



TREATMENT OF WOUNDS, ETC. 299 

Sterilization of Accessory Apparatus and Instruments. — By 
these are meant inhalers, mouth-gags, tongue-forceps, throat-mops or 
sponges, hypodermic syringes, and hypodermic solutions. As the so-called 
Esmarch inhaler or its modification for chloroform, Allis's for ether, 
or the extemporized towel cone, have nearly superseded all others in 
this country, their disinfection will be now considered. Mouth-gag, 
forceps, and throat-sponges must also be sterilized, and for similar 
reasons — viz. the danger of conveying syphilis from patient to patient or 
the introduction into the oral passages of pathogenic germs. Fatal 
results from sepsis, tetanus, and malignant oedema having followed hypo- 
dermic injections, and tedious convalescences from the effects of dirty 
needles have so often occurred that asepsis is essential. No solution 
should ever be employed which has not been subjected to boiling — best 
just previous to use. The hypodermic pellet or drug, the needle, and 
the water can all easily be boiled for a few minutes in a spoon over a 
gas-jet, lamp, or even a wax or ordinary match. The syringe itself 
should be occasionally filled with warm water, placed in the same, and 
carefully boiled. This is recommended because, while repeated rinsing 
out with boiling water has been proved to be efficient, and ought to be 
employed before using, yet additional precautions should be adopted 
where such instruments are in constant use. Aspirating apparatus 
when the direct method is used must be disinfected in a similar manner ; 
but the indirect method — i. e. Avhere a reservoir is used — is to be pre- 
ferred, as the syringe never becomes contaminated. Brisk friction of 
the skin for a minute with alcohol, followed by a germicidal solution, 
must precede the introduction of the needle. 

Sterilization of Dressings. 

Materials. — Cheese-cloth, butter-cloth, cotton, jute, moss, pine- 
sawdust, peat, ashes, asbestos-wool, sand, and innumerable absorbent 
substances have been employed, but cheese-cloth, butter-cloth, cotton, 
sawdust, and moss are those which are most available. As we have 
seen, moisture is essential to germ-life, therefore an ideal dressing must 
(1) desiccate the wound — i. e. promptly abstract the wound-secretions, 
absorb them, and permit rapid evaporation of the fluid portions ; (2) 
they must be aseptic, and (3) capable of maintaining this by preventing 
multiplication of germs. The first requisite is secured by removing all 
oily material from the cheese-cloth, cotton, or textile fabric employed 
by boiling for fifteen to thirty minutes in a solution containing 5 per 
cent, of washing soda, rinsing out in cold water, and drying. Butter- 
cloth does not require this treatment. Sawdust, oakum, and all kinds 
of gauze or moss must be sterilized by dry or moist heat or by immer- 
sion in a germicidal fluid if moist dressings are to be employed. If this 
is not convenient, they can be sterilized and remain in boxes, such as 
recommended by Schimmelbusch, or in sterilized fruit-jars. 1 

Maintenance of the aseptic state of the dressings of an aseptic ope- 
ration is secured by their arrangement in such a manner as will favor the 
drying of wound-secretions as soon as possible after their absorption. 
Exposure for thirty minutes to steam in any steam sterilizer, such as 
that of Schimmelbusch or Arnold, which fulfils the indications of pre- 



300 INJURY AND REPAIR. 

vious warming of the dressings and generation of steam under some 
pressure will secure dry, efficiently sterilized dressings. 

Chemical sterilization is often effected by corrosive sublimate — when 
not contraindicated — employed in the strength of 1 : 2000. The gauze 
(if possibly previously sterilized by heat), cut and folded, ' should be 
steeped in the solution, not be merely dipped in, and when applied 
wrung as dry as possible. But formalin sterilization is the most easy 
and effective. 

Sponges. — These may be marine, but those made of knitting wool, 
absorbent cotton, or wood-wool loosely gathered up and secured within 
a double layer of absorbent gauze, or pads of sterilized gauze so folded 
as to prevent ravellings being left in the wound, are preferable for most 
purposes, because both cheap and sterilizable by heat. 

Sterilization of Marine Sponges. — Beat with stick or in large mortar to free from 
sand ; place for twenty-four hours in potassium-permanganate solution 1 : 500 ; 
transfer to 1 per cent, sodium-subsulphate solution containing 8 per cent, by vol- 
ume of hydrochloric acid (C. P.) for fifteen minutes ; remove all traces of this by 
repeated rinsing in sterilized water and store in 5 per cent, watery solution of car- 
bolic acid ; when used they must be freed of the carbolic acid by rinsing in steril- 
ized water. 

Sterilization by heat can be done thus : free from sand ; wash and then mace- 
rate in water seven to fourteen days ; wash in warm water and place in a muslin 
bag ; immerse for thirty minutes in 1 per cent, soda solution removed from the fire 
when actively boiling ; rinse in cold sterilized water while yet in the bag ; store 
in sublimate or carbolic-acid solution. 

All forms of gauze sponges and pads should be boiled for fifteen minutes in the 
1 per cent, soda solution or subjected to the action of steam for thirty minutes. 

Sterilization op Ligature and Suture Materials. 

Heat is again superior to chemicals, and can be employed in a num- 
ber of ways : usually both methods are combined. For metallic wire, 
horsehair, silkworm gut, silk or flax thread, after loosely rolling on glass 
spools or rods, boil for thirty minutes in a soda solution and store in a 
5 per cent, carbolic-acid or a 1 : 3000 corrosive-sublimate solution or in 
previously boiled absolute alcohol. 

Catgut or Other Animal Ligatures. — Roll loosely on glass rods or 
spools ; place in large jar of absolute alcohol with screw cap or in pre- 
serve-jar, with cover, in either case only moderately tightly closed to 
prevent unnecessary waste of alcohol ; place in water-bath and subject 
to boiling temperature for two hours ; screw cover down firmly and 
keep stored. 

Brunner's Method. — Subject the gut, immersed in xylene in a closed vessel, to 
steam (100° C.) for three hours; wash in alcohol and store in alcoholic solution of 
bichloride 1 : 2000. 

Schimmelbusch' s and Bergmann's Method. — PI ace receptacle and glass spools in a 
steam sterilizer for forty-five minutes or boil in soda solution ; then roll the catgut 
on spools and soak in ether for twenty-four hours to remove grease ; pour off ether 
and substitute a solution of corrosive sublimate parts 10, absolute alcohol parts 
800, distilled water 200 parts; replace this in twenty-four hours, because it will 
become turbid ; allow the gut to remain for seventy-two hours ; store in the same 
solution, or, if stiff gut is desired, in absolute alcohol (boiled) ; if moderately stiff, 
add 20 per cent, of glycerin to the alcohol (both boiled). 

Aseptic Solutions ; Chemical Germicides ; Antiseptic Ointments. 
— Sterilized Salt Solution. — This is a 6 per mille solution of sodium 
chloride prepared by boiling for fifteen minutes. 



TREATMENT OF WOUNDS, ETC. 301 

Corrosive Sublimate. — As most waters contain lime, which decomposes 
this drug, acetic, tartaric, citric, or some mineral acid, as hydrochloric, 
or table salt must be added. The vegetable acids and table salt may be 
added in the same quantities as the mercurial salt, the hydrochloric so 
as to render the solution faintly acid to litmus. Moreover, these acids 
prevent the formation of an inert albuminate when used in the wound. 

The silver salts introduced by Credo, though not so generally used, are 
even more effective than those of mercury. Of these the lactate is the 
more soluble, and may be used in strengths of 1 to 300 down to 1 to 
1000. The citrate is used in the proportion of 1 to 1000 or 1 to 3000. 

Iodoform is invaluable, acting by virtue of the iodine set free in the 
presence of infected living tissues, neutralizing the ptomaines, etc. and 
inhibiting germ-growth. It is poisonous, especially to the old and 
anaemic, and often produces dermatitis. As iodoform gauze it is the chief 
reliance in the oral, rectal, vaginal, and vesical cavities when secondary 
suture is to be employed, as a protective dam in various conditions, and 
as packing to arrest oozing after certain abdominal operations. Slight 
poisoning is shown by headache, mental depression, anorexia, or nausea 
and vomiting; more severe cases exhibit insomnia, have a rapid pulse, 
high temperature, delirium, sometimes maniacal, coma, and convulsions : 
iodine can be detected in the urine. These symptoms may develop early 
or late, may disappear upon the removal of the dressing, or may per- 
sist — most often follow the use of large amounts, but the reverse has 
been observed. 

Numerous substitutes for iodoform are now upon the market, many 
of which are superior to it as an antiseptic, and are free from odor. 
They are for the most part patented or more or less secret preparations, 
yet many of them have undoubted value. Among them are loretin, 
xeroform, nosophen, eka-iodoform, bitmuth mbiodide, and orthoform, the 
latter having very marked local anaesthetic properties ; indeed so marked 
are these that it makes an ideal application to many irritable ulcers and 
cancers, especially of mucous surfaces. Naphthalan is also a powerful 
antiseptic with which gauze, etc., may be prepared. 

Treatment of Wounds. 

A wound is a solution of continuity suddenly effected by anything 
which cuts or tears. When the skin remains intact the injury is a sub- 
cutaneous wound, and little if any constitutional symptoms result, the 
lesion being repaired by those reparative processes erroneously called 
simple adhesive inflammation or aseptic inflammation. Wounds are 
termed incised when caused by a sharp-edged object; contused, when 
produced by a more diffused force dividing the tissues, leaving the 
wound-surfaces bruised ; lacerated, when irregularly torn ; punctured, 
when the depth much exceeds the superficial area. 

Incised Wounds. — The pain is apt to be less than in the other 
varieties, because the tissues are cleanly divided, the vulnerating object 
not dragging upon or injuring contiguous sensitive parts. Bleeding 
tends to be freer than in lacerated or contused wounds, varying with the 
vascularity or structure of the tissues. Thus, facial wounds bleed freely, 
even if no considerable vessel be divided ; scalp-wounds, not only because 



302 INJURY AND REPAIR. 

of the free blood-supply, but because the vessels cannot readily contract 
and retract in the dense tissues. Ketraction of the edges of incised 
wounds always occurs, varying with the subjacent structures and the line 
pursued. Proper planning of incisions therefore may lessen the number 
of sutures requisite. Skin and fascial wounds passing across the course 
of underlying muscular fibres gape widely. If made parallel to their 
course, they will remain in contact or require but few sutures. Skin 
and muscle retract most freely when the former is divided across the 
line of cleavage, the latter at right angles to its fibres : inflammatory 
tension of subjacent parts increases gaping. 

Union of Incised "Wounds. —Under proper treatment (see p. 286) 
the normal reparative processes described in Chapter XXIII. effect 
repair. Locally, where the epithelium is thin, the wound-edges may 
present a faint blush for forty-eight to seventy-two hours : they are per- 
haps slightly swollen, warmer than normal, and tender ; but all these 
symptoms are often absent. Although union appears to be firm at the 
end of seventy-two hours, it is mechanical, not vital — i. e. it is a mere 
gluing together by cellular exudate and fibrin. A few days suffice to 
complete true healing, a narrow reddened line indicating the former cut, 
which gradually fades until only a faint white scar remains. 

If true inflammation — i. e. germ-infection — occur, the faintly reddened wound- 
edges soon become decidedly reddened, swollen, and tense ; throbbing pain is com- 
plained" of, union fails, and pus appears. A chill or rigor may occur, but some 
headache, fever, anorexia with coated tongue, and constipation are noticed in vary- 
ing degrees, with diminution in and high color of the urine. Symptoms of nerv- 
ous disturbance, varying from mere restlessness to delirium, will make their 
appearance: septic traumatic fever has commenced. With effective drainage and 
antisepsis both local and general symptoms tend to diminish and disappear, but 
healing now can only occur by granulation, the old " healing by the second inten- 
tion." When two surfaces covered by healthy aseptic granulations can be main- 
tained in contact, fusion often occurs, and healing by "secondary adhesion" or by 
" third intention " takes place : upon this fact depends the success of secondary 
suturing. 

Treatment. — Sterilization of hands, instruments, and the surround- 
ing parts must precede examination of any variety of accidentally in- 
flicted wound. Bleeding may temporarily be checked by a tourniquet, 
pressure on the main vessel, or aseptic compression in the wound. Arrest 
the hemorrhage permanently by torsion or ligature. After some opera- 
tions, even when all visible bleeding points have been tied, free oozing 
persists, notably in some cases of intracranial excision of the semilunar 
ganglion or brain-tumors. Again, in all wounds of cerebral sinuses or 
other large veins ligatures may be difficult of application. In either 
instance, especially the former, tamponade with iodoform gauze should 
be employed. If the oozing has been mainly from small veins, forty- 
eight hours commonly suffices, when secondary suturing may be done, 
the wound healing as if primary closure had been made. If a large 
vein has to be occluded, at least a week should elapse before removal 
of the packing. 

Remove foreign bodies with forceps and clean the surfaces with a gen- 
tle stream of aseptic salt solution, sterilized water, or antiseptic lotion, 
carefully avoiding distention of the wound-cavity. If the dry method 
of operating be employed, gentle pressure with sterilized gauze pads or 



TREATMENT OF WOUNDS, ETC. 303 



absorbent cotton serves for cleansing. With an irregular, deep wound, 
especially in poorly vascularized tissues, one of two courses must be pur- 
sued : (1) buried sutures must be so disposed as to efface all spaces in 
which blood or serum can collect, or (2) free exit mmt be afforded, pri- 
marily for blood, later for exuded serum : although the coagulable por- 
tion of wound-discharges contains enough nucleins to be germicidal, 
serum does not. Drainage is only requisite for an aseptic wound for 
twenty-four to forty-eight hours to prevent the accumulation of serum 
which will break down the mechanical bond of union effected by the 
coagulated exudate, and thus delay union. If infection has taken place 
or the success of disinfection be doubted, drainage is certainly indicated 
until the dangers of sepsis are passed. Rest of the parts by position, 
splints, compresses, and gentle bandaging will secure prompt union of 
the deep as well as superficial parts, thus doing away with much of the 
necessity otherwise arising for drainage. 

Incised wounds are best closed by sutures, which may be interrupted 
or continuous. Union of cut muscle with muscle, fascia with fascia, and 
skin with skin by buried sutures is the ideal plan, the skin stitches being 
passed through the dense corium, avoiding the epithelium with its pos- 
sible germs and stitch-abscesses and the certain scarring of the needle- 
punctures. 

When strain is probable on the coaptating sutures, relaxation sutures may be 
employed, but are seldom requisite. Absorbable sutures are preferable, especially 
when buried, because not giving rise to future trouble, as the non -absorbable some- 
times do, nor requiring removal when passed through the skin. Any pliable sub- 
stance, such as silk, silkworm gut, catgut, kangaroo tendon, or silver wire, can, 
however, be safely employed for a perfectly septic wound. 

Indication for Change of Dressing. — Dressings should never be 
changed except for good cause. If penetrated by discharge at some spot 
or spots, and prompt drying at the margins of the stained area tends to 
occur, a pad of aseptic gauze had better be secured over the stained 
spot rather than undress the wound ; but if the dressings are thoroughly 
soaked, the superficial portions must be changed, leaving those immedi- 
ately related to the wound unchanged if possible. When drainage-tubes 
require removal dressings must be changed, usually about the fourth 
day. If filled with firm clot, the wound is aseptic and the tube should 
not be replaced ; when doubt exists as to the asepticity, drainage had 
better be continued until this question is settled. A sustained tempera- 
ture unexplainable by complications external to the wound demands 
inspection, since drainage may be defective or infection have occurred. 

Constitutional Effects of Wounds. — It is a common mistake to 
expect no constitutional symptoms after wounds or operations, and when 
they arise to ascribe them invariably to infection. After the nausea, 
vomiting, pain, and often subnormal temperature of the first few hours 
some rise of temperature occurs in about two-thirds of thoroughly 
aseptic cases, but the patient has a clean, moist tongue, the pulse is not 
usually much accelerated, the appetite is unimpaired, and the intellect clear. 

Symptoms of Lacerated and Contused Wounds. — As some 
degree of contusion is usually combined with laceration, these two 
classes of wounds will be considered together. Pain is greater than in 
incised wounds, but hemorrhage is not so marked. Where contusion 



304 INJURY AND REPAIR. 

preponderates, much blood is extravasated in the tissues, interfering 
with the circulation ; hence sloughing is usually proportionate to the 
contusion, as is also the risk of secondary hemorrhage when the dead 
parts separate. Sloughing and profuse suppuration will occur in a certain 
proportion of cases despite all efforts at antisepsis. Septic cellulitis and 
gangrene and any form of sepsis may occur, the former often resulting 
in extensive sloughing and producing serious scarring. 

Treatment op Lacerated and Contused Wounds. — It is diffi- 
cult to render these wounds thoroughly aseptic, but no reasonable effort 
should be spared. Temporary sterilized or antiseptic dressings must be 
used until efficient antisepsis can be secured. The preliminary precau- 
tions mentioned under Incised Wounds must be adopted. Free irriga- 
tion with an efficient chemical germicide should be employed, exposing 
and disinfecting under anaesthesia if necessary every recess. Many 
cases will do better with light iodoform-gauze packing. When seen 
later, after infection is well advanced, incisions to liberate pus, sloughs, 
and the contained poisons, and to relieve tension, free irrigation and 
drainage by tube or packing, or by both, become requisite. If the form 
and location of the wound ensures free escape of wound-fluids, no drain- 
age is requisite, but if drainage is needed, tubes must be employed until 
the discharge becomes aseptic and small in amount. 

Slight trimming of the margins of a face-wound is permissible to secure pri- 
mary union and a smaller scar, but even here unaided nature is often equal to the 
task, any serious deformity being remediable later by operation. The same advice 
applies to hopelessly damaged structures in slightly vascular parts, but for the 
scalp, oral cavity, or face the surgeon should usually rely on antisepsis. Sutures 
are only applicable to the face, where good results often follow their use. Rest 
secured by voluminous aseptic dressings, splints, and position, with (possibly) the 
external application of dry cold, is often useful. Where much contusion exists 
cold should be employed tentatively, watching lest the sloughing should be 
increased. When spreading cellulitis and free suppuration occur, proper incis- 
ions, followed by continuous antiseptic irrigation or the continuous bath — warm or 
cold according to the vitality of the tissues — is usually better than a closed 
dressing. 

Punctured Wounds. — These much exceed in depth their width, and 
result from pointed objects, as knives, swords, nails, stakes, etc. 
Especial dangers attend these wounds, such as dangerous hemorrhage 
(primary or secondary) from the deep vessels, damages to important 
nerves, penetration of cavities, and deep, widespread septic inflammation. 

Symptoms. — These must vary so with the tissues and parts involved 
— nerves, vessels, or cavities — that no general description can be given. 

Treatment. — Hemorrhage must be arrested if serious after 
enlargement of the wound. Any divided nerve must be sutured. 
Where infection has occurred thorough disinfection, including removal 
of any foreign body, must be effected by incisions, irrigations, etc. 
under anaesthesia. Drainage-tubes reaching to the bottom of the 
wound, possibly a counter-opening, and absolute rest by splint and 
position, are demanded. If septic inflammation follow, sufficient incis- 
ions, counter-openings, and the treatment suggested for contused wounds 
must be employed. If the brain-case, spinal column, thorax, or abdo- 
men be penetrated, effective disinfection and drainage are indicated, 
demanding an exploratory operation in most instances, certainly if infec- 
tion is known or strongly suspected to have occurred. 



PART V. 

SURGICAL AFFECTIONS OF THE TISSUES 
AND TISSUE-SYSTEMS. 



CHAPTER XXV. 

CYSTS AND TUMORS. 

By Roswell Park, M. D. 



General Considerations. 

A tumor is a new formation , not of inflammatory origin, characterized 
by more or less histological conformity to the tissue in which it has origi- 
nated, and having no physiological function. 

The above is perhaps as good a working definition of the term 
tumor as can be given in a few words. Nevertheless, it needs explana- 
tion in more than one direction. By the above definition it is purposely 
intended to separate the new growths now to be considered from a dis- 
tinctive class of neoplasms which are positively of inflammatory (i. e. 
of infectious) origin, to which the generic term of infectious granulomata 
has been given, and which have been dealt with as amply as space will 
allow in Part II. 

In the past exceedingly vague notions have prevailed concerning the 
nature and origin of tumors, and, while the clinical observations of writ- 
ers of past generations will never lose their value, the ideas which have 
prevailed concerning their pathology constitute interesting reading in a 
historical sense, but are now of relatively small value. Accurate notions 
scarcely prevailed until Virchow, for instance, demonstrated that tumor- 
cells in no wise differ from cell-types which are met with either in em- 
bryonic or in adult tissues. Tumors, like all other parts of the body, 
are built up of cells, and the points concerning which we now most want 
light are with regard to the influences which determine cell over-produc- 
tion in these characteristic forms. Concerning the variety of views that 
have prevailed at different times (their number being large), this is 
scarcely the place in which to offer even an epitome. I shall therefore 
take up but few of the numerous explanations which have been offered to 
account for tumor-growth, and mustemphasize distinctly, and at the outset, 
that, according to our present light, there is no one explanation sufficient 
to cover all cases, but that in all probability it is now one cause and 
now another which may determine this peculiar form of cell-activity. 

20 305 



306 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

Irritation and Trauma.- — The effort is often made to explain the 
presence of tumors upon the hypothesis or the known fact of some 
previous injury, trifling or serious. It undoubtedly is often the case 
that tumors appear in sites where there have been previous traumatisms, 
but this sequence of events by no means proves a definite relation of 
cause and effect. On the other hand, there are certain forms of irrita- 
tion which are so often followed by tumor-formations that one is never 
surprised upon meeting with them. Probably no woman escapes with- 
out one or more bumps or bruises upon the breast, yet they do not pro- 
duce tumors of the breast in anything more than a very trifling propor- 
tion of cases. Per contra, upon the lower lip of inveterate clay-pipe 
smokers and the scrotum of chimney-sweepers there develop certain 
forms of malignant ulcer (epithelioma), which so often and so signifi- 
cantly follow upon the irritation thus produced that it is impossible 
to avoid conviction that one is the cause of the other. Should events 
prove the parasitic nature of any of these growths, they may also prove 
that the irritation causes surface lesions through which infection easily 
occurs. At all events, at present it may be accepted as a fact that 
tumors, benign and malignant, not infrequently follow irritation and 
trauma, but by no means with certainty. 

Inflammation. — This must refer to inflammation in the sense in 
which it has been used by older writers, implying a very variable con- 
dition, sometimes including, sometimes excluding infection, and being a 
term covering a somewhat confused mixture of irritation, hyperemia, 
infection, etc. In so far as it concerns inflammation as considered in the 
present work, it should not be here included, since inflammation (i. e. 
infection) produces neoplasms of a class considered in Part II. and dis- 
tinctly ruled out from present consideration (/. e. the infectious granu- 
lomata). 

If, then, while inflammation in this former sense is more than hyper- 
semia, it may be regarded as predisposing to cell-activity, but not neces- 
sarily to tumor-formation as distinguished from hypertrophy of a given 
part or tissue. If it refer to irritation, this has been already acknow- 
ledged as one factor in the etiology of tumors, but as a very uncertain 
one. The cancer of the gall-bladder or liver which occasionally results 
from the irritation of a gall-stone, or the cancer of the breast that fol- 
lows eczema of the nipple, may be regarded in this light as additional 
illustrations if one prefers to interpret them in this way. If, finally, by 
inflammation be meant the infectious granulomata, they have already 
been considered. As the term " inflammation " can scarcely mean any- 
thing except hypersemia, irritation, or infection, we seem to have pretty 
completely ruled it out from consideration as by itself an active cause 
leading to tumor-formation. 

The Embryonal Hypothesis of Cohnheim. — This in its ingenuity 
and in its applicability is a most fascinating explanation, which is 
undoubtedly sufficient for at least a certain number of instances. 
According to Cohnheim, only one causal factor for tumors ' exists — i. e. 
anomalous embryonic arrangement. He regards them as entirely of 
embryonal origin, no matter how late in life they may develop and 
appear. Briefly summarizing his views, they are to the effect that in 
the early stages of embryonal development there are produced more 



PLATE XII. 







@ 




( 



1 J? 




9 



/2 m 






13 






a 



16 






-<? 



\ 







a 



// 



ILLUSTRATIONS OF THE ALLEGED PARASITES OF CANCER. 

i. A free rarasitc subdividing into Leucocytiform and Granular bodies. 

2. Two free Parasites — the upper dividing into round Daughter-cells ; the lower dividing into 
Leucocytiform Cells, simulating Phagocytosis. (After Jackson Clarke; Zeiss 1-12; Bioudi's stain.) 

3-7. Sporozoa of Sarcoma (?). Developmental Stages; the cell represented in 3 had a diameter ot 
one mikron. 

8, 9. Nuclei of Sarcoma Cells appearing through the Sporozoa (i. e., transluccncy of the latter). 

in, 11, Sporozoa free in the Connective Tissue; a, Youngest or smallest. 

12. Nuclear division in Sporozoon. 

13, 14. Hndogeuous division of the Sporozoon. (After Vedeler.) 

15. Free Parasite in the Cell of an Alveolar Sarcoma; /i, Nuclei; a, Chromatin bodies; 6, Spore; 
c, Parasite (Acinetaria). 

16. Free Parasite; a, Krythrophile portions ; b, Chromatin Zone; c, Cytoplasm of the Parasite. 

17. Free Parasite undergoing Mitotic division. (After Jackson Clarke; Biondi-Hhrlich stain.) 



CYSTS AND TUMORS. 



307 



cells than are necessary for the construction of a certain part, so that a 
certain number of them remain superfluous. While this number may 
remain very small, they possess, on account of their embryonal nature, 
a most potent proliferating power. This superfluous cell-material may 
be distributed uniformly, in which case it will develop whole system- 
arrangements, like supernumerary fingers, etc., or it may remain by 
itself in one place, and will then develop a tumor. In this latter case 
the tumor may appear promptly or not until late in life, according to 
the time at which the cell-collection receives the necessary stimulus, or 
because of its suppression by resistance of surrounding structures. It 
mav be an irritation or an injury, such as above alluded to, which shall 
give it this stimulus ; as, for example, it is reasonable to think that cer- 
tain nsevi and other congenital conditions which develop later into can- 
cers do so in accordance with this view. Surgeons generally find little 
fault with Cohnheim's hypothesis, except that as yet they decline to see 
in it an explanation for all cases. Nevertheless, for dermoid and tera- 
tomatous tumors and for all heteroblastic tumors it seems to afford the 
only tenable explanation, Thus, chondroma of the parotid and of the 
testicle are most easily explained in this way, and that cartilaginous 
islands occur in the shafts of adult bones is well known. 

The parasitic theory of tumor-formation is one which has been 
vaguely hinted at for a considerable length of time, and which has only 
very lately taken anything like distinctive form. It implies that tumors 
(and most writers limit it to the malignant tumors) are due to the 
irritation produced by parasitic agents of some kind, which, introduced 
from without, act as do the bacteria in the now well-known infectious 
granulomata. This also is in certain respects a satisfactory theory, and 
has more or less in clinical experience to justify it, while, at the same 
time, at present there is but little upon which men can agree in the mi- 
croscopical appearances of these growths to corroborate it (Plate XII.). 

At present students are concentrating their investigations mainly upon the 
class of unicellular animal organisms belonging in a general way to the coccidia. 
It is definitely established that coccidia, which are a class of the sporozoa, are the 
cause of certain well-known disease-mani- 
festations in the lower animals, as, for ex- 
ample, in the livers of rabbits. Minute 
organisms, resembling these, differently 
classified and regarded by different in- 
vestigators, have been found in and about 
the distinctive cells of numerous cancers 
and sarcomas, and have given rise to the 
greatest difference of opinion, some hold- 
ing that they were there accidentally, 
some that they were the actual disease- 
agents, and others that the bodies thus 
regarded by some as parasitic animal 
forms were in effect mere evidences of 
karyokinetic cell-division or of breaking 
up, in some sense, of cell-contents or tissue- 
debris ; in other words, that they were not 
parasites at all, but results rather than 
causes of disease. At present writing the 
controversy is still actively waged, and 
one may not yet surely say which party Psorosperms in rabbit's liver (Spencer, J" obj.). 
in the discussion is correct. From the 
pathological side the principal objections to this view are that these little bodies 



Fig. 83. 




308 AFFECTIONS OF THtJ TISSUES AND TISSUE-SYSTEMS. 

have not yet been positively identified by enough observers to justify their accept- 
ance by all, and that so far their endeavor to cultivate and inoculate them has 
failed. It should be emphasized that it is not claimed that any of these organisms 
are bacteria, but it is generally supposed that they belong rather to the animal 
than to the vegetable world. From the clinical side there is much to justify the 
parasitic theory. That cancer prevails in certain families and localities, and even 
in certain houses (the so-called cancer-houses), is now well established; that it is 
capable of being spread from one part of the body to another by mere contact is 
established, as from the lower to the upper lip, from one labium to the other, etc. ; 
and that it acts in almost every way as do well-known parasitic lesions is fre- 
quently seen. Thus, its contagiousness and inoculability have received enough clini- 
cal demonstration to be suggestive, if not widely acceptable as definitive ; and, in 
spite of all statements to the contrary, there are enough inoculation-experiments 
from man to the lower animals or from these to each other to place it now beyond 
possibility of denial that cancer can be transmitted from man to the animals. It 
is, then, not yet possible to state with any distinctness that the parasitic theory of 
tumor-formation is as yet tenable. One must, at least, however, say that it has 
much to commend it, and that it certainly deserves the earnest consideration of 
individuals and the collective investigation of the entire profession. 

Nomenclature . 

As may be expected, when one takes into consideration the crude 
notions and the vague, contradictory statements that have obtained in 
the past concerning the nature of tumors, their nomenclature has been 
sadly confused ; and if some new terms are introduced to-day, it is 
wise, perhaps, rather than to hold to some of those which have done 
duty in the past for varied and varying conditions. Various systems 
have been followed of naming them according to their supposed nature 
or their evident tendency, or according to some purely arbitrary classifi- 
cation ; thus we have the distinction into homologous and heterologous or 
heteroblastic, according as they are similar to or variant from that tissue 
in which they seem to originate, or they have been spoken of as benign 
and malignant according to the disposition which they evince ; and 
these terms are to-day in sufficiently frequent use to demand acceptance. 
In fact, the distinction as between benign and malignant is both con- 
venient and in some respects accurate, implying little with regard to 
histological structure, but everything with regard to their effect upon 
the individual. 

So far as method of classification goes, the anatomical ( i. e. the histo- 
logical) has proven so far the most satisfactory, and is that which is now 
everywhere adopted. It is the basis for the classification followed in 
the ensuing pages. But even here it is impossible to maintain abrupt 
or always accurate distinctions, because tumors are frequently of mixed 
type, and require us, if we desire to express their composition by their 
names, to sometimes combine words in an awkward fashion. By com- 
mon consent that tissue which predominates furnishes the concluding 
portion of the compound term, while by prefixing other terms we 
endeavor to imply the composite character of the neoplasm. 

Thus we have osleo-chondroma, fibro-myoma, myo-fibroma, etc., and it is neces- 
sary often to reduplicate terms in order to be accurate in description. While this 
complicates phraseology, it nevertheless furnishes to the intelligent reader a 
reliable clue as to the general character of such a growth ; and if one reads, for 
instance, of a myxo-chondro-sarcoma, he promptly infers therefrom that he has to 
deal with a tumor essentially a sarcoma, in which both myxomatous degeneration 
and cartilaginous formation have taken place. In the same way, the prefix cysto 



CYSTS AND TUMORS. 309 

is frequently used to imply a combination of originally solid tumor which had 
undergone cystic changes in whole or in part. 

The old term cele is even to-day frequently used as a suffix, implying neo- 
plastic changes in an organ, or at least the formation there of a tumor. Thus we 
have bronchocele, hydrocele, cystocele, etc. Again, certain terms are now used in a 
different sense from that originally intended. Thus, the term sarcoma now has a 
definite significance, whereas originally it had little meaning and was applied 
inadequately and indiscriminately. Old terms also, like fungus hmmatodes, are now 
used rather in a descriptive sense, because for any such tumor on accurate 
examination we can find a proper term taken from descriptive pathology. Con- 
sequently, it happens that the student of to-day must read the works of the older 
writers, especially concerning neoplasms, with a certain amount of intelligence, as 
well as of apology for the inaccuracy and misnomers of the past. 



Treatment. 

The results of treatment of tumors leave much still to be desired, 
particularly when dealing with those of malignant nature. So far as 
purely internal treatment is concerned, we have not yet discovered 
drugs which with any certainty influence cell-growth to the extent of 
making them reliable or effective. In the past, and even the present, 
numerous remedies have been advocated as having more or less of 
power in this direction. Of them all it is probable that arsenic in some 
form is more efficacious than any other. This is certainly true in the 
case of the disease elsewhere spoken of as malignant lymphoma, or Hodg- 
hin's disease, which partakes much of the character of some of the other 
neoplasms. But to say that arsenic alone or any other known remedy 
can be relied upon at all times is probably going too far. 

The treatment of all operable tumors, then, is essentially surgical 
(i. e. operative), although it must be confessed that to a large extent 
results are based upon the essential character of individual tumors. 
But at least this much can be positively stated, that to be successful in 
the removal of any tumor its complete extirpation is demanded. Even 
the most benign tumors will return if only partially removed. This is 
true even of innocent cysts, which will often be re-formed if a portion 
of the cyst-wall be allowed to remain. Complete extirpation is ordi- 
narily a simple measure when tumors are encapsulated, as many of the 
innocent tumors often are. On the other hand, the performance of 
some of these operations is made difficult and hazardous by the location 
of the tumor, as in many large uterine fibroids, tumors of the thyroid, 
etc. But when dealing with malignant tumors the only secret of suc- 
cess is to extirpate them in the most merciless possible manner, sacri- 
ficing everything which may appear to be involved, unless, like a large 
blood-vessel or important organ, it be essential to the life of the part or 
of the individual. These general statements are made when speaking 
of tumors in a general way. More particular directions will be given 
when dealing with particular forms or in the chapter on Special and 
Regional Surgery. 

Classification. 
Following custom in large degree, yet being guided by generally 
undeniable facts concerning histological structure, tumors will be classi- 
fied and considered as follows : 



310 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

1. Cysts. 

2. Dermoids. 

3. Teratomata. 

4. Tumors of immature mesoblastic tissue-type. 

5. Tumors of simple mesoblastic tissue-type. 

6. Tumors of more complex mesoblastic tissue-type. 

7. Tumors of epithelial type or of epiblastic origin. 

8. Tumors of glandular tissue-type. 

9. Tumors of endothelial type. 

1. CYSTS. 

A cyst may be defined as a tumor containing one or more cavities 
filled with fluid or semifluid content*. This specifies nothing with regard 
to the location nor the character of the cyst-wall nor the nature of the 
fluid contents. Following Sutton, I divide cysts into four groups : 

1. Retention-cysts. 

2. Tubulo-cysts. 

3. Hydroceles or Distention-cysts. 

4. Gland-cysts. 

Retention-cysts. — These imply a previously existing cavity whose 
outlet is obstructed and whose contents consequently accumulate, often 
to such a degree that the original character of both containing wall and 
contained fluid is entirely altered. When this occurs in glands or gland- 
ducts there is usually complete atrophy of gland-tissue, providing suf- 
ficient time have elapsed. Such cysts are, then, due either to permanent 
or temporary arrest of flow. In hydronephrosis, for example, there is 
obstruction of the renal outlet and dilatation of its pelvis, with partial 
or complete atrophy of the kidney-structure, until a cyst of enormous 
size may be present. When a similar condition obtains in the uterus, as 
by obstruction of the cervix, perhaps due to injury done during labor, 
we have a condition known as hydrometra, seen occasionally in women, 
often in the lower animals, and particularly in those having a bicornate 
uterus, causing a condition often mistaken for an enormously dilated 
Fallopian tube. Similarly, when the common bile-duct is obstructed, 
which may be due to impacted gall-stones, to inflammatory lesions, 
tumors, etc., we may have such backing up of bile in the gall-bladder as 
to produce the condition known as hydrocholecyst. 

Under any of these circumstances pyogenic bacteria may produce infection 
which will be more or less promptly followed by suppuration ; and then, instead 
of hydronephrosis, hydrometra, hydrosalpinx, etc., we get pyonephrosis, pyometra, and 
pyosalpinx. 

Tubulo-oysts. — These are cystic dilatations of certain functionless 
ducts and obsolete canals which no longer serve a useful purpose. They 
comprise — 

1. Cysts of the Vitel/o-i ntestinal Duct. — Cysts originating from this 
functionless duct occupy the umbilical region, sometimes projecting exter- 
nally, sometimes internally. They are usually lined with mucous mem- 
brane furnished with villi and columnar epithelium. Such a cyst may 
possibly be confounded with an umbilical hernia. These cysts occasion- 
ally open at the umbilicus and discharge irritating material, sometimes 



CYSTS AND TUMORS. 311 

fecal matter. Cystic dilatation of the portion of the duct originally 
connected with the ileum is also occasionally met with. 

2. Allantoic Oysts. — These are connected with the uracil us, which 
should ordinarily be found as a fibrous cord, but which occasionally per- 
sists in a pervious condition, in whole or in part. At birth it is often 
traversed by a very narrow canal lined with epithelium continuous with 
that of the "bladder. The urachus lies outside the peritoneum, and may 
be dilated at any point between its two extremities. When the entire 
urachus is pervious urine is discharged from the navel. 

3. Oysts connected with Remains of the Wolffian Body. — The Wolffian 
body, or the mesonephros, is intimately related with the development of 
the kidney, the ovary, and the testis. In the two latter locations glan- 
dular elements may be met with, persisting in adult life. 

In the male the tubules persist as excretory ducts from the testis, but in the female 
they persist in a vestigial condition as the parovarium and Gartner's ducts. The 
ovary proper consists of the oophoron and the ■paroophoron, the former being the egg- 
bearing portion, the latter receiving the tubules from the adjoining structure 
known as the parovarium. The •paroophoron gives rise to cysts which burrow 
deeply between the layers of the broad ligament, make their way alongside the 
uterus, and raise the peritoneum. It is a peculiarity of these cysts that their inner 
walls often become papillomatous, and may even develop such a crop of warty out- 
growths that these make their way through the cyst-wall and protrude into the 
abdominal cavity, where they sometimes become detached and are dropped as loose 
bodies into the peritoneal sae. The condition is also often accompanied by warty 
growths upon the peritoneal surfaces. These need give rise to no alarm, because 
they usually disappear spontaneously with removal of the tumor. Paroophoritic cysts 
are to be distinguished from parovarian cysts, which develop from the parovarium, 
this latter consisting of a number of tubules situated between the layers of the meso- 
salpinx, composed of an outer series of tubules known asKobelt's, an inner set, abouta 
dozen in number, known as the vertical tubules, with a straight tube running at 
right angles to these through the broad ligament to the vagina, known as Gart- 
ner's duct, which is homologous with the vas deferens of the male. Cystic dilata- 
tion of Kobelt's tubes is often met with, these cysts being very small and having no 
clinical importance. Cysts arising from the vertical tubules are usually transpar- 
ent until they attain considerable size, when their walls thicken. Their contained 
fluid is not harmful, and after rupture of such cysts internally the fluid is absorbed, 
and thus disposed of. Such cysts may rupture and refill several times. As between 
the paroophorous and parovarian cysts, the latter are usually easily enucleated, carry 
the ovary upon one side, and have the Fallopian tube stretched over them without 
communication. 

The internal sections of Gartner's duct are more often involved in animals than 
in women, but excellent illustrations of cystic dilatation of its various portions 
have been met with, usually in the walls of the vagina. 

Corresponding to the above-mentioned conditions met with in the female we 
find in the male, as the result of changes in the Wolffian body, two quite common 
conditions — encysted hydrocele, of the testicle and general cystic degeneration of the same. 
Like the ovary, the testicle is a complex organ with remnants of the mesonephros 
persisting among its ducts, while only a few of the Wolffian tubules remain. True 
encysted hydroceles arise sometimes in the efferent tubes of the testis, and some- 
times in Kobelt's tubes (the same structures which in the female give rise to 
parovarian cysts), the two conditions, therefore, being analogous and homologous. 
These cysts, though closely associated with the testis, lie outside its tunica vagi- 
nalis. Their contained fluid is usually clear or of a milky whiteness, due to fat- 
globules. Sometimes it contains spermatozoa. Another variety is cystic dilata- 
tion of one or more of Kobelt's tubules, which is often described as involving the 
hydatid of Morgagni. 

General cystic disease of the testis, known also as adenomatous degeneration, was 
formerly spoken of as hydatid disease of the same organ. The multiple cysts 
appear to originate in the remnant of the mesonephros still persisting known as the 
paradidymis. The cavities are lined with epithelium, and papillomatous intracystic 



312 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

formation is not uncommon. These tumors in time past have been unfortunately 
spoken of by a number of improper names, such as " cystic sarcoma," etc. 

Hydroceles. — In time past this name also has been made to cover a 
multitude of conditions. At present, by common consent, when no 
other locality is spoken of, hydrocele of the tunica vaginalis is under- 
stood. (The term really implies a collection of watery fluid in a pre- 
viously existing serous cavity.) This is the most common form. 

Possibility of its formation depends upon the prolongation of the peritoneal 
cavity, which takes places in advance of or along with the descending testicle, and 
which in almost all the lower animals remains connected with the general cavity 
throughout life. In men only is' it expected to close, even before birth. When 
the portion which extends along the spermatic cord is not completely obliterated 
we have encysted hydrocele of the cord, or funicular hydrocele, which is not common. 
The common form of hydrocele is constituted by serous effusion into the tunica 
vaginalis, and occurs usually without recognizable exciting cause. It will be 
treated of more fully in its appropriate place in Volume II. 

The corresponding process of peritoneum in the female is known as the canal 
of Mick; and, when persistent, this also becomes distended with fluid and forms 
a cyst known as hydrocele of the canal of Nuck, occupying the inguinal canal. 

In many of the lower animals the ovaries are contained within a serous sac 
derived from the peritoneum which is connected with the opening of the Fallopian 
tubes, so that when the ova escape from the ovary they enter these tubes and pass 
to the uterus without entering the general peritoneal cavity. This ovarian sac is 
subject to serous distention, and constitutes a condition named by Sutton as 
ovarian hydrocele. An homologous condition obtains sometimes in the human 
female by pathological adhesion, and such cysts sometimes attain large size. They 
project from, and are intimately connected with, the posterior layer of the broad 
ligament. 

Hydroceles of the neck, so called, are cystic collections of con- 
genital origin found in the cervical region, due to dilatation of ducts or 
clefts which should have disappeared at or before birth. The form of 
cyst to which the name of " hydrocele of the neck " is usually limited 
is recognizable at or soon after birth, and constitutes a fluctuating 
tumor, often extending beneath the clavicle into the axilla or down upon 
the thorax. They may occupy the entire lateral region of the neck, and 
may be unilateral or bilateral — may be single or multilocular, and may 
even intercommunicate. 

They originate always beneath the deep fascia. Some of these cysts are 
undoubtedly due to dilatation of lymph-spaces. This is particularly true of the 
multilocular forms. There is noted in many of them a tendency toward spontane- 
ous recovery, but many of them require operative measures for their eradication. 
Occasionally their walls are extremely vascular, even to the degree meriting the 
term nosvoid. 

Some of these cysts are considered by Sutton to be essentially examples of the 
laryngeal saccules which are met with as diverticula from the laryngeal mucous 
membrane, which undermine the deep cervical fascia? of certain monkeys. These 
air-chambers, which are normal in the monkey, communicate with the larynx 
through the thyro-hyoid membrane, and occasionally run down beneath the upper 
border of the thorax. Many of the cysts having this resemblance are closely 
related to the hyoid bone and to the larynx, and there is very much to substantiate 
the view thus alluded to. 

Glandular Cysts. — Ranula is an altogether too comprehensive term 
which has long been used in surgery, alluding to certain cysts met with 
for the most part in the floor of the mouth, and not indicating minutely 
their character nor their exact location. At present this term should 
either be restricted in signification or, perhaps, better still, be elimi- 



CYSTS AND TUMORS. 313 

nated. If used, it should be confined to retention-cysts due to obstruc- 
tion of the submaxillar}/ or sublingual ducts. Such obstruction is often 
caused by salivary calculi impacted in the duct-orifices. In other 
instances it is due to cohesion of the margins of the outlet. A similar 
condition in the parotid duct is known, but is very much less common. 
Aside from this, certain other cysts originate from minute beginnings 
in and about the floor of the mouth, being due to dilatation of the 
mucous glands, particularly one near the tip of the tongue, sometimes 
known as Nuhn's gland. Dermoid cysts in this locality are not uncom- 
mon. In time past every cyst of the floor of the mouth was described 
as ranula.. 

Pancreatic cysts correspond in large degree to salivary cysts, the 
pancreatic duct becoming dilated by retention when its orifice is 
obscured ; and, indeed, the condition has been spoken of as pancreatic 
ramda. Sometimes the canal is dilated in distinct portions, so that the 
condition resembles a string of cysts ; at other times it is the terminal 
portion which is most enlarged. Such cysts attain large size and con- 
tain for the most part mucoid material. Examples have even been 
reported showing that they have attained a capacity of two gallons. 

In the mesentery there sometimes develop cysts which are known as 
chyle-cysts, whose sacs appear to be formed of separate mesenteric layers, 
their cavity being occupied by fluid identical with chyle. Such tumors 
also sometimes attain great size. 

In the eyelids one occasionally meets with cystic dilatations of the 
lachrymal ducts. These are known as dacryopic cysts or dacryops. 
Fistula? result when they are opened through the skin, and if meddled 
with at all they should be radically extirpated. 

Pseudo-cysts. 

In his elaborate work on tumors Sutton has made a distinct classifi- 
cation of pseudo-cysts, which lack some of the characteristics of genuine 
cysts, yet, nevertheless, are entitled to consideration in this place. 
Among these are included intestinal diverticula and vesical diverticula, in 
either of which instances hernial protrusions of the mucous membrane 
through the outer coating of the bowel or of the bladder occur, thus 
forming pouches. These are common in the bowel, rare in the bladder; 
especially in the former locality they are often multiple. This condi- 
tion is often spoken of as sacculation; &t\d sacculation of the bladder 
may even be confounded with true urachus-cyst. They are of little 
consequence so long as foreign materials, such as faeces, urinary calculi, 
etc., do not lodge in them. 

Pharyngeal diverticula give rise to rare but most interesting tumors. 
It is well known that the branchial clefts, which in early foetal life con- 
nect with the pharynx, are sometimes not completely closed, and that a 
portion of one may persist abnormally, giving rise to a condition known 
as the pouch of Rathke. There may also occur sacculation of the 
pharyngeal wall where it joins the oesophagus, or hernial protrusions, 
especially in Rosenmuller's fossa ; also sacculations or diverticula of the 
bladder, which are especially often seen ill connection with inguinal 
hernise. 



314 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

Cystic dilatation of Rathke's pouch occurs near the upper part of the pharynx, 
and may attain the size of a marble. Hernial pouches are seldom mistaken for 
cysts, and are of importance mainly because of the fact that food or other foreign 
material gathers and lodges in them. Most of the other cystic abnormalities of 
the pharynx pertain to dermoids, and will be considered shortly. In a general 
way, these pharyngeal tumors have been grouped as pharyngoceles. 

Similarly, in the oesophagus and trachea hernial protrusions occur, and lesions 
closely resembling retention-cysts may be met with. 

Synovial cysts (i. e. those containing synovial fluid) may arise (1) by 
protrusion of synovial sheaths ; (2) by distention of bursas in the vicinity 
of joints ; or (3) by hernial protrusions of joint membranes. They are 
often met with in connection with the larger joints, more particularly 
perhaps about the knee. In this way tumors as large as goose-eggs 
may be formed, while their location may be so shifted that they present 
themselves in perplexing ways. To that form produced by hernial pro- 
trusion of the lining of a tendon-sheath has been given the name gan- 
glion. 

The simple ganglion is most often seen on the back of the wrist, and, while it 
is often only connected with the tendon-sheath, it undoubtedly frequently con- 
nects with the synovial membrane of the carpal joints. The compound ganglion, 
so called, is a much more serious and extensive affair, being one which has pro- 
longations in two or more directions, and usually containing peculiar bodies, 
known commonly as melon-seed bodies, which appear to be fibrinous concretions 
worn round and smooth by attrition. These are present sometimes in enormous 
numbers. ( Vide Tuberculosis of Synovial Structures, Chapter IX.) 

Bursoe are normal in many well-known situations in the body, but 
may undergo cystic dilatation and become annoying tumors. In many 
other places, under the influence of friction or mechanical irritation, 
there develop bursse which are known as adventitious. These are some- 
times subtendinous, and may communicate alike with joint- and tendon- 
sheaths. These are true cysts of new formation not developed from a 
pre-existing cavity. 

They are largely the effect of peculiar occupation, as in housemaids and carpet- 
layers there frequently is formed a prepatellar bursa, while miners get them upon 
the elbow, porters upon the shoulder, plasterers upon the forearm, etc. In the 
same way, by the pressure of ill-fitting boots, an adventitious bursa is developed 
over the expanded head of the first metacarpal bone, thus forming a condition 
known as bunion. 

Neural Cysts. 

This term has been applied by Sutton to pseudo-cystic dilatation of 
certain cavities found in the brain and central nervous system. Hydro- 
cephalus is in one sense a pseudo-cyst of this variety. Quite corre- 
sponding to it in foetal life is hydramnios. Hydrocele or cystic dilata- 
tion of the fourth ventricle is well known. Cranial uneningoceles, which 
are hernial protrusions of brain-membranes, are also pseudo-cysts, to be 
included in this category. They will be considered at due length in 
Chapter XXXVII. Cephalcemaioma might possibly be also included in 
the same way. Spina bifida, a condition to be more minutely described 
in Chapter XXXVIIL, is, nevertheless, practically, a cyst of congenital 
origin involving the spinal meninges. One form of spina bifida is con- 
stituted by cystic dilatation of the central canal of the spinal cord, and 



CYSTS AND TUMORS. 315 

produces the condition accurately spoken of as syringo-myelocele. ( Vide 
Chapters XXXVII. and XXXVIII.) 

Sutton has rendered a very great service by showing that the brain and spinal 
cord are really evolved from a segment of the primary intestine, and that the 
intestinal canal and the neural canal communicate in foetal life at their lower termina- 
tions ; while it has been shown by several that in the earlier forms of mamma- 
lian life they were also connected by their anterior terminations. It is in this way 
that certain complex and rarely met-with tumors of the sacral and coccygeal 
region are to be explained. So also is the collection of lymphoid tissue in the 
vault of the pharynx, known as Luschha's tonsil, and in the coccygeal region, 
known as Luschka's gland, it being a curious and most instructive fact that 
lymphoid tissue of this character always is met with in the neighborhood of obso- 
lete canals. 

Hydatid Cysts. 

Hydatid cysts constitute a distinct class of pseudo-cysts due to the 
presence of parasites. In this particular instance it is the ordinary 
tape-worm (Taenia echinococcus), whose adult form inhabits the intes- 
tines of dogs, and whose eggs are conveyed either with food or drink 
into the alimentary passages of man, where they are hatched, while the 
embryo, migrating into some distant organ or tissue vid some blood- 
vessel, gradually becomes transformed into a cyst whose wall has a 
peculiar structure and which is usually surrounded by a fibrous capsule. 

Cystic Degenerations. 

Another term used in connection with many tumors or cystic forma- 
tions must be defined here. Hematocele is an expression meaning a 
tumor composed originally of effused blood which has undergone chemi- 
cal and other changes, which consist of lamination and thickening of its 
exterior portion and fluidification of the interior, until in course of time 
such an internal blood-clot may be converted into a distinct and plainly 
walled cyst. This condition is met with especially often in two loca- 
tions — namely, in the pelvis and between the cranium and the brain, or in 
the brain, where distinct and beautiful illustrations are not infrequently 
met with. As time goes on the haemoglobin entirely disappears, and the 
contents of these cysts are translucent or even watery in appearance. 
Hematoceles may form where there has been internal hemorrhage in 
certain locations which has failed to absorb, and where no pyogenic 
infection has occurred. 

Pseudo-cystic changes occur in many other tumors and in other parts 
of the body as the result of mucoid and colloid liquefactions — conditions 
which are amply described in works on general pathology. Suffice it to 
say here that in the midst even of apparently dense and entirely defined 
tumor-masses changes of this kind occur, and lead to formation of cavi- 
ties containing fluid of variable consistence, causing the tumor when 
divided to present much the appearance of the geodes or quartz rocks 
containing cavities lined with quartz crystals. The occurrence of such 
cystic changes is indicated in naming such a tumor by prefixing the 
term cysto-, as cysto-sarcoma, cysto-fibroma, etc. 



316 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 



2. DERMOIDS. 

Dermoids are cysts or tumors containing tissues and appendages which 
are developed from the epiblast, and which occur very often where skin 
and mucous membrane are not normally found. The simplest form of 
dermoid is a cyst whose interior is lined with modified skin, containing 
sebaceous glands and hair-follicles, from which often numerous long 
hairs are produced. Even sweat-glands may be present. Its cavity is 
occupied by mixed material, pultaceous in character, made up of sebum, 
cholesterine, and growing hairs which are often rolled into balls. The 
sebum is the product of the glands contained in the cyst-wall. 

A more complex form of so-called dermoid cyst is met with, in 
which we find unstriped muscle-fibre, teeth, mammary glands, etc. 
These, strictly speaking, belong rather to the class of teratomata, since 
they contain more or less tissue not of epiblastic origin. 

A dermoid tumor is one lacking cystic characteristics, made up of 
tissue largely developed from the epiblast, with more or less tissue of 
mesoblastic origin. Such a tumor may contain much connective tissue, 
fat, foetal hyaline cartilage, and even nerve-tissue, while from its exte- 
rior long hair may grow, and teeth may project from its" surface or be 
imbedded within its substance. Such tumors are most often found in 
the pharynx and about the rectum. 

The whole explanation of dermoids and teratomata must be gleaned 
from embryology, and rests upon the combined arrangement of the dif- 
ferent blastodermic layers of the developing ovum and upon the facts 
already alluded to in explaining Cohnheim's hypothesis of the origin of 
tumors. Strictly speaking, a dermoid should contain only that which 
may be developed from the epiblastic layer. It is well known that teeth 
and hair, as well as sebaceous material, are epiblastic products. Conse- 
quently, such material may be found within a dermoid and call for no 
further explanation than an epiblastic inclusion, according to Cohnheim's 
views. But, so soon as such a tumor contains bone, muscle, etc. (i. e. 
tissues of mesoblastic origin) we should, strictly speaking, drop the term 
dermoid and consider it a teratoma. Such is the accurate distinction 
between these two terms. 

The most prominent characteristics of dermoid cysts are — First, skin, which 
may be thick or thin, lined with papillae, containing more or less pigment, its 
deeper layers possessing a quantity of fat. Second, hair, which next to skin is the 
most constant structure found in dermoids ; this may be present in very trifling 
amount or in long coils or balls. It is of interest that in dermoids found in ani- 
mals covered with wool we find the same character of hairy structure, while in 
birds dermoids contain feathers rather than hairs. Third, sebaceous glands and 
their peculiar secretion are almost invariably found. These may be of large size, 
and sebaceous retention-cysts may be seen in the walls of dermoids. Sometimes 
horny matter or tissue is found in these, indicating the same relation between horn 
and sebaceous structures as we see upon the external skin in other instances. So, 
too, material resembling the texture of finger-nails is occasionally found project- 
ing into the cavity. 

The fluid or semifluid contents of these cysts consist usually of sebaceous mate- 
rial, cholesterine, epithelial debris, etc. Sometimes it is thick, sometimes thin — 
sometimes consists almost entirely of mucus. 

It is not uncommon to find structures in ovarian dermoids closely 
analogous to, or actually resembling, mammary glands. These may be 



CYSTS AND TUMORS. 317 

mere nipple-like processes of skin, or completely developed mammee, 
well formed, but without ducts or gland-tissue, may occupy such a cyst. 
These really are pseudo-mammae, because they have no ducts. Never- 
theless, glandular tissue is not always absent. This resemblance pro- 
ceeds even further, in that in some of these ovarian mammae changes 
occur analogous to those which take place in normal breasts. 

The epiblast seems to have the power of developing mammary glands or super- 
numerary mammse in many locations — in fact, upon any part of the body-surface. 
About the thorax they are common ; upon the abdomen they are rarely met with ; 
and they have been found even upon the labia. 

Sioeat-glandx are infrequent in dermoids. Teeth are quite common. These may 
vary in number from two or three up to several hundred — may be imbedded in 
definite sockets or simply sprout from the cyst-wall. Occasionally bone-material 
lodging such teeth and crudely resembling a jaw will be found. 

Dermoids containing mucous membrane are found, especially in con- 
nection with the ovary and with the post-anal gut (i. e. the original pas- 
sage communicating between the spinal and alimentary canals). 

It is curious that under these circumstances mucous membrane is sometimes 
furnished with hair, as it normally is in the stomach or other cavities of some of 
the lower animals. Mucous glands and retention-cysts of these glands are also 
found in ovarian dermoids. This will be much more readily understood if the 
mutability of skin and mucous membrane be not forgotten. The transition from 
one to the other is not difficult, and we find all intermediate stages between the 
two extremes — if not in man, at least in the animals. This will account also for 
the fact that skin-covered dermoid tumors are found in certain parts of the ali- 
mentary canal, and particularly in the pharynx. These tumors grow also from 
the mucous membrane of the bowel, of the rectum, or even of the small intestine. 

Sutton has made a happy division of dermoids into three classes : 

1 . Sequestration. 

2. Tubulo-dermoids. 

3. Ovarian. 

1. Sequestration dermoids occur chiefly in situations where during 
embryonic life coalescence takes place between two surfaces possessing 
an epiblastic covering, although sometimes this coalescence practically 
occurs late in life and by implantation. 

Dermoids of the trunks occur particularly where opposite halves of the body- 
wall coalesce — that is, in the mid-line of the trunk and head. Dermoid cysts are 
found rarely in connection with spina bifida, and certain tumors spoken of as spina 
bifida undoubtedly are, in effect, dermoids. Anteriorly, dermoids occur frequently 
in the scrotum, possibly occasionally in the testicles. At the umbilicus they are 
rarely met with — usually as pedunculated tumors projecting externally. In the 
mid-line of the thorax and neck they are most common opposite the manubrium, 
dropping down behind it to invade the anterior mediastinum. Near the hyoid 
bone they occur relatively frequently ; about the head they are met with most com- 
monly at the angles of the orbits — more so at the outer than the inner angle. Der- 
moid cysts are known to oculists as growing upon the iris or springing from the 
conjunctiva. About the ear they are not infrequent; in the roof of the mouth, 
especially when this be incomplete, we frequently find cysts of epiblastic origin. 

Sequestration dermoid cysts are also undoubtedly found in connection with the 
dura mater, in the scalp, most commonly at the anterior fontanelle, at the root of 
the nose, and at the external occipital protuberance, where they may be con- 
founded with sebaceous cysts or with meningoceles. In order that a dermoid of 
the dura may communicate with the skin there must of course be osseous defect. 

Sequestration dermoids upon the limbs have been mostly reported as sebaceous 
CV m?i' They are rare, and usually associated with antecedent injury, by which 
epiblastic structures are driven in and implanted in such a way that as they 



318 



AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 



develop they give rise to these peculiar tumors. These are what Sutton speaks 
of as implantation dermoids. They have been met with-upon the fingers and else- 
where. 

Tubulo-dermoids. — These are largely connected with obsolete canals 
and ducts. It is a great service which Sutton has rendered us in prov- 
ing, apparently beyond the possibility of doubt, that the central canal 
of the nervous system is really of intestinal origin, and may be regarded 
as a disused segment of the primary alimentary canal. He has shown 
also how it behaves occasionally as do other functionless ducts, and that 
cysts and dermoids in connection with it are to be thus, and thus only, 
explained. He and others have also shown the anterior as well as the 
posterior communication of these canals, and the pituitary body is to be 
regarded in this light as the same formation of lymphoid tissue around 
an obsolete canal which we see in Luschka's tonsil close by, and in 
Luschka's gland at the other extreme of the canal. 



Fig. 84. 



Fio. 85. 




Solid dermoid escaping from pelvis (original). 



Congenital dermoid cyst of pelvis (Ahlfeld). 



The primary alimentary canal, then, was a continuous tube lined with a con- 
tinuous layer of columnar epithelium. That portion connected with the yolk-sac 
develops into the intestine, the balance into the central nervous canal. Portions 
of this canal are in post-natal life absolutely obsolete ; others persist in a very 
rudimentary condition. Dermoid cysts and dermoid tumors develop in connection 
with each of these. In some of these there is a large central cavity ; others are 
almost absolutely solid. Thus we meet with dermoids in the coccygeal region 
which have been variously regarded as sarcomata, adenomata, etc., which are 



CYSTS AND TUMORS. 319 

really of origin as stated above, and which should be considered simply as der- 
moid tumors. Most of these project outwardly ; some of them arise and develop 
within the pelvis. Dermoid cysts and tumors are also met with in connection with 
the rectum — sometimes between the rectum and the bladder, sometimes between 
the rectum and the spine. Dermoid tumors are also found in connection with the 
pituitary body. These sometimes develop within the cranium, or, again, protrude 
perhaps into the orbit, perhaps into the pharynx. 

Thyroid dermoids are tumors of very great interest. They develop sometimes 
about the cranio-pharyngeal canal, which may be detected as a small canal in the 
macerated sphenoid bone of a fcetus, and which before birth is filled with fibrous 
tissue. It connects with a recess in the middle line and at the base of the skull, 
presenting in the pharynx, which is often spoken of as the bursa pharyngea. It is 
around this recess that the lymphoid tissue known as "the pharyngeal tonsil" 
develops. It may thus be expected that the roof of the pharynx should be the 
occasional site of dermoids. It is from the pharynx or the floor of the mouth that 
in vertebrata the thyroid body arises. In higher forms it becomes dissociated from 
the pharynx and shifts its position. The thyroid body is developed around the 
thyroid duct, which first appears as the thyro-hyoid duct, which later becomes 
divided, that portion in relation with the tongue becoming the thyro-lingual duct, 
the remaining portion persisting as the thyroid duct. These are present about once 
in every ten subjects, according to Sutton, the canal when persistent being lined 
with epithelium. When the extremities of these ducts become occluded, we may 
have retention-cysts. In the same way dermoids of the tongue are formed, similar 
to those occurring on the scalp. These are frequently mistaken for sebaceous cysts. 
They may be unilateral, central, or even bilateral. The lingual duct is also of 
interest, because it would appear that certain cases of epithelioma of the tongue 
arise along this duct, and perforating malignant ulcer of the tongue is thus pro- 
duced. Dermoid tumors of the lingual or thyroid ducts resemble in structure the 
thyroid body. The thyroid duct may also be detected in many adults running 
from the isthmus of the thyroid body to the posterior aspect of the hyoid bone, 
and surrounded by muscle-tissue. Sometimes the space usually occupied by this 
duct is represented by a series of detached bodies known as accessory thyroids. 
These are not infrequently the seat of cysts, sometimes of considerable size. (The 
accessory thyroids often enlarge when the main thyroid has been extirpated for 
disease.) Thus cysts in close relation to the hyoid bone are common. Some of 
them grow slowly ; others, rapidly and contain much fluid. Many of them are 
unilateral, and are often mistaken for enlargements of one lobe of the thyroid. 
Cysts growing from accessory thyroids are often filled with papillomatous masses, 
and are occasionally the seat of malignant degeneration. 

In the omphalo-mesenteric duct or its remains, especially in relation with the 
umbilicus, we often meet with small cysts or tumors in infants and young children. 
When the duct is persistent it presents normal intestinal structure, and, like the 
appendix, possesses much adenoid or lymphoid tissue. 

Another and very important form of tubulo-dermoids develops in connection 
with the branchial clefts of the neck. Congenital fistulas of the neck have been 
long known, but only comparatively recently understood. Of the branchial clefts, 
it is well known that the first alone should persist, as the Eustachian tube, etc. 
Occasionally, however, they fail to become completely obliterated, and then we 
have congenital tumors or cysts, which may, however, not develop to appreciable 
size until somewhat late in life; or we may have fistulous passages opening either 
into the pharynx or externally, forming canals varying in length from half an inch 
to two inches, secreting a little fluid because lined with epithelium. When these 
become inflamed an abscess results. When they open externally the opening is 
often marked by a little tag of skin containing a fragment of yellow cartilage. 
These are often spoken of as cervical auricles. They open usually along the line 
of the sterno-mastoid muscle. The internal openings of these fistulse frequently 
form diverticula from the pharynx or oesophagus. Thus it will be seen that der- 
moid cysts about the neck are, for the most part, relics of openings or ducts which 
are normal in embryonic life, but which should have been obliterated at or long 
before birth. Congenital fistulas, however, may be met with in the middle line of 
the neck which are not to be confounded with branchial Astute, but rather with 
the ducts previously described. 



320 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 



Ovarian Dermoids. — These may be unilocular or multilocular cysts, 
usually the latter. They are lined with epithelium, and contain for the 

most part mucoid fluid, the inner coat 
being practically identical with mucous 
membrane. Occasionally, however, 
we meet with skin furnished with 
hair, sebaceous glands, teeth, and even 
nipples. The multilocular cysts are 
practically an aggregation of those 
just described. They are surrounded 
by dense oapsules, often attain great di- 
mensions, and are made up of primary 
cysts resembling large cavities in a 
honeycombed-like mass, which itself 
is occupied by secondary cysts, and 
belong rather to the class of mucous 
retention-cysts ; and these are occupied 
by still smaller ones which are histo- 
logically indistinguishable from dis- 
tended ovarian follicles. In these 
large tumors we find in some cases 
hair, in others teeth, in yet others sebaceous glands, etc., the dermoid 
constituents being scattered throughout. 




Ovarian dermoid, showing ball of hair 
(original) . 



3. TERATOMATA. 

So far, I have endeavored to limit the term dermoid to tumors which 
are essentially of epiblastic formation, which, nevertheless, may be pres- 
ent in deep situations, their location here to be explained on the inclusion 
theory of Cohnheim. There is next to be dealt with a still more com- 
plicated type of tumor, composed of tissues of both epiblastic and meso- 
blastic origin, perhaps even hypoblastic, whose structure is too complicated 
to be taken up at length in this place. Their consideration belongs 
rather to that department of pathology known as Teratology, which is 
supposed to deal especially with monsters. Strictly speaking, a teratoma 
refers to an irregular tumor or mass containing tissues and fragments 
of viscera of a suppressed foetus which is attached to an otherwise nor- 
mal individual. Nevertheless, the term is often applied to growths 
which are the result of luxuriant mesoblastic development in which 
yet neither form nor member of a suppressed fetus is present. 

As between exaggerated mesoblastic growth in this direction, which supposes 
the presence of a single ovum or the presence of supernumerary members, even 
to the extent of conjoined twins, which presupposes two distinct embryos, one of 
which goes on to complete development, while only certain parts of its companion 
develop, we cannot stop here to go into minutise. The presBnce of supernumerary 
members is largely connected with what is called dichotomy, alluding thereby to 
cleavage either at the anterior or posterior end of the developing embryo. When 
the whole embryonic axis divides twins may be produced, but should cleavage be par- 
tial we may have a monster with two heads if it be anterior, or if it be posterior 
with three or more limbs. Children born with these deformities are usually spoken 
of as monster*, and the study of such cases belongs entirely to teratology. But in 
certain tumors small portions of a suppressed foetus may develop, as, for instance, 
from the posterior portion of the sacrum, or within the abdomen or thorax, or 



CYSTS AND TUMORS. 321 

upon the neck or face, which on dissection may contain a few vertebrae or pro- 
cesses resembling fingers, associated perhaps with a structure resembling intestine 
or liver. This is what should be spoken of as a true teratoma. Such tumors 
possess for the pathologist the greatest value, In surgery, however, they are rare, 
and there are scarcely two cases alike. The question of operation will often come 
up, as it does with supernumerary limbs, and each case must be studied and decided 
purely upon its own merits. Sometimes they are amenable to extirpation. 

Teratomatous tumors are sometimes found hanging in the pharynx, 
attached by a small pedicle. In this location they are likely to be con- 
founded with dermoids unless carefully examined after removal. Many 
instances of this type of tumor are met with in animals. Here no false 
sentiment will prevent complete examination and preservation of the 
specimen. (For further information, however, the reader must be re- 
ferred to the large works on Teratology or to works like those of Sutton 
on Tumors.) 

4. TUMOES OF IMMATURE MESOBLASTIC-TISSUE TYPE. 

Sarcoma. 

To these the now well-defined and perfectly understood name of 
Sarcoma is given. In times past this name, which simply implies a 
fleshy tumor, has been made to cover many different conditions, and the 
reader of literature of forty years or more ago may be much misled by the 
use of this term in many significations. To-day sarcoma means a tumor 
composed of immature mesoblastie or embryonic tissue in which cells predomi- 
nate over intercellular material. Sarcomata are sometimes encapsulated : 
they merge into and infiltrate the surrounding tissue and disseminate 
widely, and for the most part have these propensities and characteristics 
to such a degree as to constitute malignancy. For the laity sarcomata 
and carcinomata are together included in the comprehensive term of 
cancer ; for us they may constitute but one form of cancer. Sarcomata 
are classified, according to the shape of their cells and their disposition, 
into — 

A. Round-celled, 

B. Spindle-celled, 

C. Myeloid, 

D. Alveolar, and 

E. Melano-sarcoma. 

A variety of the round-celled sarcomata is also distinguished as 
lymphosarcoma. 

A. Round-celled Sarcoma. — This is simple in construction, and 
consists of round cells containing very little intercellular substance. 
The nuclei of the tumor-cells stain easily, the cells themselves varying 
very much in size in different cases. Blood-vessels lead up to the 
tumor, but in the interior appear rather as channels. These tumors 
have no lymphatics : they grow rapidly, infiltrate easily, recur quickly, 
and give rise to numerous metastatic or secondary deposits. They may 
affect any part of the human body. The size of the cells is supposed to 
be in some measure an index of their malignancy — the smaller the cell the 
more malignant the tumor. They appear at all periods of life. They 
are perhaps the most commonly met with of malignant tumors in animals. 

Lympho-sarcoma. — This is composed of cells similar to the pre- 
21 



322 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 



vious form, but enclosed in a delicate meshwork resembling that of 
lymph-nodes, hence the term lymphosarcoma. Lympho-sarcomata are 



Fig. 87. 




Fig. 88. 



Recurring sarcoma of parotid (original). 

not to be confounded with enlargements nor with the specific granu- 
lomata involving these lymphatic structures. 

B. Spindle-celled Sarcoma. — In this form the cells have a spindle 
shape and run in all directions, so 
that sections will show them in 
various shapes and sizes. In some 
cases the cells are very small and 
slender, in others very large. Here, 
again, the size of the cell is a meas- 
ure of the malignancy of the tumor. 

The largest type of these spindle-cells 
is frequently striated transversely like 
voluntary muscle-fibre, and tumors com- 
posed of this form have been considered 
as tumors of striped muscle-tissue, and 
have usually been called rhabdomyoma. 
Strictly speaking, there is no tumor of 
striped muscle-fibre, and the rhabdomy- 
omata of writers generally must be con- 
sidered as spindle-celled sarcoma or may 
be dignified by the name myosarcoma. In 
these growths also one occasionally meets 
with immature cartilage, sometimes even 
to such an extent that they are regarded as cartilaginous rather than sarcomatous, 




Spindle-cell sarcoma of thyroid (X X"! 
Spencer). 



CYSTS AND TUMORS. 323 

this cartilage frequently calcifying, sometimes even ossifying. The sarcomatous (*'. e. 
the malignant) character of these tumors is clinically demonstrated, if not micro- 
scopically betokened, by the frequency with which they recur after removal. In 
certain spindle-celled sarcomata, however, the cells sometimes undergo conversion 
into fibrous tissue, and may then be spoken of as fibrosarcoma or fibrifying sarcoma. 




Sarcoma of femur following fracture— i. e. developing in callus (original). 

C. Myeloid or Giant-celled Sarcoma. — In this form the tissue 
resembles histologically the red marrow of young and growing bone, 
containing large numbers of multinuclear cells imbedded in a matrix of 
spindle- or round cells. These tumors, for the most part, occur in the 
long bones, and when freshly cut look much like a piece of liver. 

Giant or multinuclear cells should be present in relatively considerable num- 
bers to entitle a tumor to classification in this group. When round, spindle-, or 
giant cells mingle in nearly equal proportion, the tumor should be spoken of as a 
mixed-cell sarcoma. 

T>. Alveolar Sarcoma. — This is a rare form, in which the cells, con- 
trary to the general rule of sarcomata, assume an alveolar arrangement 
strongly imitating that of epithelial cells in carcinoma. Almost invari- 
ably, however, on minute examination it will be possible to distinguish 
a delicate reticulum between individual cells, which is never met with 
in cancer. By some the alveolar sarcomata are grouped as belonging to 
endotheliomata {q. v.). On this point we need further light. Their 
common situation is in the skin, especially in connection with congenital 
defects, such as hairy and pigmented moles. 

E. Melano-sarcoma, sometimes known as Melanoma. — This refers to 
the deposition of pigment, rather than to type or shape of cell, the dis- 
tinguishing feature of these growths being the presence both in the cells 
and in the intercellular substance of a variable quantity of blackish 
pigment. Of all the forms, the melanotic growths are generally con- 
sidered the most malignant. They invariably recur after removal, they 
lead to secondary deposits at long distances, and they present the most 
intractable and incurable form of cancer. Deposition of pigment in 
carcinomata is most rare, if ever met with, and the growths heretofore 



324 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 



spoken of as melanotic cancer should be relegated entirely to the class 
just under consideration. ( Vide Plate XIII.) 

General Characteristics of Sarcomata. — The vascular supply of 
sarcomata varies within wide limits. In nearly all instances it is of 
capillary character, the blood circulating rather through vessels with 
well-marked walls. While large vessels may be found about and in the 
periphery of these tumors, distinct vascular structure is usually absent 
from the more internal vessels ; all of which will explain the frequency 
of hemorrhage, its persistency after operation, and the ease with which 
large extravasations occur. True hsematocele may thus take place 
within sarcomatous tumors with the usual later cystic alterations, and thus 
in one way we have the condition frequently spoken of as cysto-sarcoma. 

In attacking these growths the most 
vascular and bloody area may be met with 
just about their margins, the blood-vessels 
expanding as they arrive at the tumor, 
and bleeding sometimes furiously. Under 
most circumstances, however, this hem- 
orrhage can be controlled by packing or 
by operating at a little greater distance 
from the circumference of the growth. 

Metastasis in sarcoma is common, 
dissemination occurring mainly along 
the veins, since these growths often 
penetrate into .the venous channels 
and permit of easy detachment of 
fragments, which are then carried 
along as emboli. These emboli pass 
naturally to the right side of the 
heart, and thence to the lungs, where 
it is most common to find secondary 
growths, except in areas emptying into the "portal veins, in which case 
the liver will be the most common site. Sarcomata are destitute of 
lymphatics, and dissemination does not occur through these channels. 
Infiltration is also a common phenomenon with these growths. This 
is perhaps most often seen in muscular tissue, particularly with growths 
proceeding from the periosteum and projecting into it. 

Sarcomata, like other tumors, tend to grow along the lines of least 
resistance. Hence processes of these tumors will insinuate themselves 
into fissures and interspaces, and penetrate perhaps even into the cavi- 
ties, from which it is hazardous or impossible to remove them. Thus, 
sarcomata springing from the head of a rib have been known to extend 
through an intervertebral foramen and give rise to an intraspinal tumor, 
causing fatal pressure. 

Secondary changes are commonly met with in sarcomata, the most 
frequent being hemorrhage. Myxomatous degeneration is also frequent, 
and gives rise to cystic conditions. Calcification is common, particu- 
larly in the more slowly-growing tumors which arise from bone. Upon 
the other hand, necrosis (i. e. ulceration) is common in growths which 
project upon the surface or into any of the open cavities of the body. 
Ulceration here is simply an expression of growth at a rate relatively 
faster than the possibilities of nutrition permit, and gangrene is to be 




Angiosarcoma: blood-vessel with coagu- 
lated blood (X %"; Spencer). 



PLATE XIII. 




Melano-Sarcoma of Skin; a, Stroma with Pigment Cells; 

b, Endothelial Cell Nests with Migrated 

Pigment Cells. (Klebs.) 



CYSTS AND TUMORS. 325 

regarded as a failure to supply sufficient blood. It may also mean infec- 
tion, of which it is, indeed, a usual expression. 

Tumors of this character, which luxuriate upon reaching the surface, 
and which bleed easily upon the slightest touch, were known in time past 
as fungus hcematodes. The name may be preserved for the sake of con- 
venience, but should be held to mean in almost every instance a rapidly- 
growing, round-celled sarcoma. 

Sarcoma is common in the lower animals, particularly so in horses — 
most common in those of gray color. It is met with also in cows and 
various other domestic and undomesticated animals. 

Glioma. 

Glioma, by some regarded as a variety of sarcoma, is by others (e. g. 
Sutton) considered as a distinct variety of tumor. Inasmuch as the 
nervous system is really of epiblastic origin, it is questionable whether 
gliomata may not, after all, belong in Group VII., Tumors of Epithelial 
or Hypoblastic Origin. For purposes of simplification, at least, it may be 
well included here as a type of sarcoma. It consists of delicate con- 
nective tissue, identical with that which is known in the histology of the 
nervou,s system as neuroglia. It bears the same relation to the central 
nervous system that plexiform neuroma bears to peripheral nerves. It 
occurs only in the former — that is, in the brain, in the spinal cord, and 
perhaps in the optic nerve. Structurally, it consists of cells with delicate 
ramifying processes held in place by fibrous tissue. Gliomata are 
usually quite vascular, the vessels being even sometimes sacculated. 
For the most part these tumors are solitary — i. e. do not give rise to 
secondary deposits. When near the surface of the cortex such a tumor 
may appear like an enormous convolution (Virchow). In the basal 
portions of the brain these tumors may attain considerable size. 

Gliomata in the spinal cord are rare, occurring twenty times as often 
in the brain as in the cord. In the latter location they are usually 
indistinctly outlined and cause a general enlargement of the cord. They 
may occur anywhere along its length, but are most common in the 
cervical portion. They are most common also between the fifteenth 
and thirtieth years of life, but may be met with in old age. The 
symptoms of these growths consist usually of pressure-effects, and it is 
ordinarily impossible to diagnose them before either operation or autopsy. 
If attacked at all, they need to be most radically extirpated, else these, 
like sarcomata in general, are most prone to return. 

5. TUMOES OF SIMPLE MESOBLASTIC-TISSUE TYPE. 

Lipoma. 

Lipomata, or tumors composed of fat, are the most commonly met 
with of all neoplasms. Their normal type is the ordinary adipose tissue 
of the body, while, anatomically, they may be divided into the encap- 
sulated and the diffuse, the former of which are surrounded by more or 
less of an investment of fibrous tissue by which a certain form and 
integrity are preserved. The diffuse lipomata are those which are pos- 
sessed of no capsule, where the pathological collection of fat merges 
into that normally present — in other words, they are not circumscribed. 



326 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

Subcutaneous Kpomata are perhaps the most common of all, and are usually 
irregularly lobulated and encapsulated, adherent rather to the skin than to the 
deeper tissues. Usually but one is found in a given individual, though instances 
of multiple lipomata are not rare. They develop sometimes to enormous size, 
cases being ou record where the tumor has even weighed one hundred pounds. 
They may be met with at any point on the surface of the body. The lobules often 
burrow between the muscles, and those found in the palm of the hand penetrate 
even beneath the palmar fasciae. They are sometimes markedly pedunculated, and 
hang often by a small stem. The diffuse subcutaneous lipoma is most common 
about the neck ; next most common in the groin and axilla. 

Subserous lipomata are for the most part retroperitoneal, and very large tumors 
of this character, mistaken for ovarian tumors, have been successfully removed by 
operation. In the hernial canals and spaces they also are met with. They develop, 
moreover, beneath the peritoneum covering the intestines, and in this location they 
give rise occasionally to intussusception. Here they have the general form and 
significance of appendices epiploicx in their pathological development. 

Subsynovial lipomata occur about various joints and tendon-sheaths ; especially 
within the knee they assume a distinctive type which has been called lipoma 
arborescens, where they take on a dendritic appearance and arrangement. Submucous 
lipomata are rare. Intermuscular fatty tumors are occasionally met with, an inter- 
esting variety being that which develops between the masseter and buccinator 
muscles. Intramuscular forms are also rarely met with, as well as a variety known 
as parosteal, which arise in connection with the periosteum. Fatty tumors also 
occur within the spinal dura, as well as outside of it within the spinal canal, 
and more or less lipomatous alterations are common in connection with spina 
bifida. 

Lipomata are ordinarily easy of recognition, save when deeply located. 
The subcutaneous forms are intimately related with the overlying skin, 
and have a dough-like consistence which is usually pathognomonic. Those 
tumors, suspected to be fatty, which are met with in the middle line of 
the back or cranium are always to be viewed with suspicion, since they 
are often connected with congenital meningeal protrusions. 

An encapsulated lipoma, when thoroughly removed, will not return. 
It is when one deals with the diffuse variety that he often finds inter- 
ference unsatisfactory or regrets that he has attempted it, the difficulty 
being in knowing where to stop. 

Mixed forms of fibrous and fatty neoplasm are not infrequently met 
with, which may be spoken of as lipoma fibromatosum or fibroma lipoma- 
tosum according as one or the other tissue predominates. These growths 
are innocent in their character, but call for thorough extirpation. They 
frequently give rise to considerable discomfort or pain — so much so that 
they have been spoken of as lipoma dolorosa. 

Pibeoma. 

Fibromata are tumors composed of fibrous tissue, which, when of 
pure type, are found to be not so common as was formerly supposed, the 
majority of tumors hitherto roughly grouped as fibromata containing 
either muscle-tissue or sarcomatous elements, which takes them out of 
the category of pure fibroma. A typical fibroma is ordinarily dense, 
and is composed of wavy bundles of fibrous tissue whose cells are long 
and slender and closely packed together, the mass being permeated by 
distinct blood-vessels. 

Fibroma occurs most commonly in the ovary, the uterus, the intestine, 
the gum (epulis), in nerve-sheaths, and in the skin in the form of so-called 



PLATE XIV. 









' - 












; i -':i^ 



Keloid of External Ear. 

«, Dense Tissue of Skin; A, Fibrous Connective Tissue; r. Epidermis. 



(Klebs.) 



CYSTS AND TUMORS. 



327 



painful subcutaneous tubercles and molluscum fibrosum. There is also a 
fibrous tumor of the skin, known as keloid, sustaining to fibroma the 
same relation that obtains between exostosis and osteoma. 

The painful subcutaneous tubercle of many writers is a sample of pure fibroma 
in the shape of a small, flattened pea-like tumor which never attains great size. 
It is situated loosely in the subcutaneous structure and may form a visible prom- 
inence. Insignificant as it would thus appear, it becomes the seat of exasperating 
pain, particularly when touched or handled : this may radiate to considerable dis- 
tances. The etiology of these little growths is absolutely unknown. 

In the ovary, the uterus, the intestine, and the larynx pure fibrous tumors are 
pathological curiosities rather than common lesions. 

Epulis means, in effect, any tumor growing upon the gum. The term was 
formerly applied in an indistinct and too comprehensive way, although it is still 
retained in literature. But pure fibromata do spring from the fibro-osseous struc- 
ture of the gum and alveolar process. They are covered with the gingival mucous 
membrane and seem to spring from the periodontal membrane. They seldom 
attain large size; then only through neglect. By the pressure of such tumors 
teeth may be separated and no little distortion of the mouth produced. 

Keloid is a fibrous neoplasm arising, for the most part, in cicatricial 
tissue, which is essentially fibroid in structure. It is a neoplasm which 
often follows the general outline of the scar in which it grows, consists 
in elevation of the surface, ordinarily quite smooth, sometimes of a 
delicate pink from the dilated vessels which it contains. Keloid is the 
bite noir of surgeons, since it frequently complicates and disfigures scars 
which have been at first perfectly satisfactory, and since it indicates a 
condition which it is discouraging to deal with, because when it is 
removed there is usually recurrence of growth within a few months 
after cicatrization. It occurs often in stitch-hole scars and upon the 
site of extensive burns, may be met with after puncture of the ears for 
ear-rings, and has also been observed in scars left by smallpox, acne, 
etc. It is more prevalent in the col- 
ored than in the white race. In negroes FlG - 9l 
multiple keloid tumors are often seen, 
occasionally even in large numbers. 
Their explanation is unknown, and it 
may be that some trifling injury has 
preceded each individual tumor. Vide 
Plate XIV. 




Chondroma. 

The true chondroma is a tumor 
composed of hyaline cartilage. It 
occurs most often and typically in 
the long bones, usually in relation 
with epiphyseal cartilages, and, con- 
sequently, is most often noted during 
the earlier years of life. While it 
is usually a solitary tumor, multiple 
chondromata are often seen, especially upon the hands. These tumors 
are often encapsulated, and form deep hollows in which they rest. 
Unless pressing upon nerve-trunks, they are painless and slow of 
growth. They are exceedingly dense and hard, and ordinarily immov- 



Enchondroma from inner aspect of pelvis 
(contributed by Dr. Holloway). 



328 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

able. Mucoid softening (i. e. cystic degeneration) is common, and the 
softened areas may give rise to fluctuation. There may be coincident 
calcification or ossification in any of these growths. It is noted as a 
curious circumstance, by Sutton, that their tissue resembles histologi- 



Fig. 92. 




Multiple enchondromata (contributed by Dr. Holloway). 



cally the bluish, translucent epiphyseal cartilage which is seen in pro- 
gressive rickets. 

To the small local hypertrophies of cartilage which are seen especially about 
joints, about the laryngeal cartilages and the triangular cartilage of the nose, are 
given the term ecchondroses. They are most common in the knee in connection with 
rheumatoid arthritis, and occur as prominences along the margins of the joint- 
cartilage. They may project to such an extent as to be detached by accident, after 
which they become movable and floating bodies in the joints. Many of the float- 
ing cartilages or bodies found in joints are, in other words, detached ecchondroses, 



CYSTS AND TUMORS. 



329 



which may be smoothed off by attrition, and which may be found singly or multi- 
ple, even several hundred existing in one joint. 

Chondromatous changes as occurring in sarcomatous tumors have already been 
alluded to. It seems to be easy for connective tissue to form hyaline cartilage, 
and mixed tumors may thus be met with in connection either with sarcoma, 
fibroma, or other forms. 

The treatment of chondroma is solely operative. Unless the 
integrity of a member or a limb be compromised, such a tumor can usu- 
ally be shelled out from its location, but requires that the matrix be 
completely extirpated ; all of which may call for the use of powerful 
bone-instruments. At other times amputation is the only measure 
which may relieve from deformity, pain, and disability. The eechon- 
droses occurring within joints call usually for incision and evacuation 
with the most rigid aseptic precautions, with or without drainage, as the 
case may be ; when practised according to modern technique this is 
almost invariably successful. In former times many lives were lost 
because of septic infection, which is now avoidable. 

Osteoma. 

Under the head of Nomenclature I have already endeavored to dis- 
tinguish as between exostosis, or irregular bone-outgrowth, and oste- 
oma, as a distinct tumor which is composed of bone-tissue, with the 
subvariety odontoma, or tumors of dental origin and structure. Oste- 
oma is regarded by some as ossifying chondroma, since it is nearly 

Fig. 93. 




Double osteoma of skull (Musee Dupuytren). 

always found near epiphyseal lines, and is always covered by hyaline 
cartilage when thus found. Nevertheless, it is not invariably such. 
We speak of compact or ivory osteoma and of a cancellous form. The 
former is identical with the compact tissue of the shafts of long bones, 
and may occur anywhere, but is most common about the cranium, at the 
frontal sinus, the external meatus, and the mastoid process. Osteomata 
growing into the frontal sinus of oxen, for instance, form large lobulated 
bony masses, sometimes weighing several pounds and as dense as ivory. 
Some of these tumors growing into the cranial cavity have been 
absurdly regarded as ossified brains. Osteomata in connection with the 
external auditory meatus partially or completely obscure this channel 
and cause deafness. They constitute ivory-hke growths, which defy 
sometimes the finest steel instruments with which the surgeon can sup- 
ply himself. 



330 



AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 





Fig. 94. 


A 












s 'di-'- 


^V / 




' '■' ~~~ .■ . 


. 4 - 




' ' 


'■^L ■ ■ . ; > ■■-■'" 



Osteoma of frontal sinus (Neisser). 



Cancellous osteoraata grow in the cranium as well as in the long 
bones, and, like the compact forms, only occasion pain by pressure upon 

nerve-trunks. 

Exostoses are classed by Sutton as — 

(1) Those formed by ossification of 
tendons and their attachments. One 
should exclude from this group such 
natural or evolutionary processes as 
the superior condyloid process, the third 
trochanter of the femur, etc. Over or 
around such exostoses bursse will form 
to mitigate as much as possible the effect 
of friction. 

(2) Subungual exostoses, occurring 
usually beneath the nail of the big toe. 

(3) Exostoses due to calcification of in - 
flammatory exudations, incl uding the rare 
condition known as myositis ossificans. 

When a true osteoma is once 
thoroughly removed there is no tend- 
ency to recurrence. Thorough removal, 
however, calls sometimes for serious 
and often mutilating operations, which 
may become dangerous when the growth 
involves the curve of a rib or a large 

portion of the skull. At other times amputation is rendered necessary. 

Special forms call for special treatment suitable to the case in hand. 

Odontoma. 1 

The odontomata are tumors composed of one or more of the dental 
tissues, arising either from tooth-changes or teeth in process of develop- 
ment. They may be divided, according to Sutton, as follows : 

(a) Epithelial Odontomata. — These are provided with a capsule, and 
present usually as a series of cysts separated by thin septa, containing 
mucoid fluid, while the growing portions have a reddish tint not unlike 
sarcoma. They are most frequent about the twentieth year of life, but 
may occur at any age. They probably arise from persistent remains of 
the epithelium of the original enamel-organs. 

(6) Follicular Odontomata. — These are often spoken of as " dentiger- 
ous cysts," a term used altogether too loosely. They arise in connection 
with permanent teeth, and especially with the molars, sometimes attain- 
ing great size and producing conspicuous deformity. The tumor con- 
sists of a wall representing the expanded tooth-follicle, and a cavity 
containing viscid fluid, with some part of an imperfectly developed 
tooth, occasionally loose, occasionally more or less displaced in location. 
The cyst-wall always contains calcareous material. These tumors 
rarely suppurate. They occur also in animals. 

1 These tumors are really of epithelial origin, since the teeth are epithelial products. 
They therefore really belong in Group VII., but are retained here because of their clini- 
cal resemblance to the osteomata, and lest previous classifications suffer too violent a 
shock. 



CYSTS AND TUMORS. 331 

(e) Fibrous Odontomata. — These consist of condensed connective 
tissue in a developing tooth, and presenting as a tumor with a firm outer 
wall and a loose inner texture, blending at the root of the tooth with 
the dental papilla and indistinguishable from it. The developing tooth 
thus becomes enclosed within the capsule before it protrudes from the 
gum. These tumors are most common in ruminants, being often mul- 
tiple. 

(d) Cementoma. — This refers to a tumor of fibrous character whose 
capsule has ossified or calcified, the developing tooth thus becoming 
imbedded in a mass of dental cementum. These tumors occur most 
frequently in horses. 

(e) Compound Follicular Odontomata. — These are tumors containing 
a number of masses of cementum resembling small teeth, or even 
amounting to well-formed but ill-shaped teeth composed of all three 
dental elements. In such a tumor teeth may be found by the score. 
They are met with in the human subject as well as in animals. 

(/) Radicular Odontomata. — These are tumors which arise after the 
crown of the tooth has been completed and while its roots are yet in 
process of formation. The crown, being unalterable enamel, does not 
enter into the composition of these growths, which then consists of 
dentine and cementum in varying proportions. These tumors are rare 
in man, but frequent in other animals, and often multiple. 

(g) Composite Odontomata. — These are hard tumors, bearing little or 
no resemblance in shape to normal teeth, occurring in the jaws, consist- 
ing of a conglomeration of enamel, dentine, and cementum, presenting 
abnormal growth of all the elements of the tooth-germ. So far, this has 
only been found in man. 

So little is said about the odontomata in general surgical literature 
that I have devoted some space to the subject here, since these tumors, 
as they grow, are often regarded as due to necrosed bone or to unerupted 
teeth, while fibrous odontomata have often been regarded as myeloid 
sarcomata. No tumor of the jaw, especially in young people, should 
lead to excision of the jaw until it has been fairly demonstrated that the 
tumor is not one of the above forms, and that it really is something call- 
ing for so severe an operation. When one has to deal with a true odon- 
toma its complete removal is all that is called for, and no further sacrifice 
of tissue is necessitated. 

Myxoma. 

The myxomata are composed of mucous tissue, whose best^known 
normal representative is the Whartonian jelly of the umbilical cord. 
True myxoma should be distinguished from myxomatous degeneration, 
which occurs frequently in cartilage, fibrous tissue, and sarcoma, and 
which brings about a similar condition of affairs, though of essentially 
different origin. Myxomata appear under the following forms : 

(a) Polypi, growing most often in the nose. The pure form of nasal 
myxoma proceeds from the mucous membrane of the nasal passages or 
sometimes from the accessory sinuses. The polypi hang usually as gelat- 
inous tumors of grayish-yellow tint, being present sometimes singly, 
sometimes in clusters or in large numbers. Their principal effect is to 
produce nasal obstruction, with, perhaps, subsequent serious disorder 



332 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

due to decomposition or to extension into the pharynx or other cavities. 
Similar growths also occur from the mucous membrane of the tympanum, 
and constitute the common variety of aural polypi. 

(6) Cutaneous myxoma is not common. It presents usually as a ses- 
sile tumor, although about the perineum and labia the tumors may 
become pedunculated. It is often difficult to distinguish between a 
myxoma of the skin and a sarcoma of the same which has undergone 
myxomatous degeneration, and which then should be strictly called sar- 
coma myxomatoses. The latter tend to recur after removal ; hence the 
importance of exact diagnosis, if possible, in which the history of the 
case will largely aid. 

(c) Neuromyxoma is a similar condition involving the nerve-trunks, 
and is dealt with rather under the heading " Neuroma." 

Myxomata require complete removal, and in the nose especially cau- 
terization or destruction of the surface from which they spring. When 
this is thoroughly done they do not recur ; otherwise, they are quite 
likely to require subsequent operation. 

Myoma. 

The true myoma is a tumor composed of unstriped. or involuntary 
muscle-fibre. Until, very recently it has been customary to divide the 
myomata into the leiomyomata in contradistinction to the rhabdomy- 
omata, the latter being supposed to be tumors of voluntary muscle-fibre. 
The latter, however, are now known to be spindle-celled sarcomata (q. v.), 
in which a certain striation of spindle-cells is often observed, and have 
been already spoken of in their proper place. Myomata, then, are met 
with only where involuntary muscle-fibre is found — namely, in the uterus 
and adnexa, the vagina, the oesophagus, alimentary canal, the prostate, 
the bladder, and the skin. They form encapsulated tumors composed of 
fusiform muscle-cells with a rod-like nucleus, the size of the cells vary- 
ing greatly in different specimens. The bundles of muscle-fibres are 
much contorted, and it is often difficult in a single section to decide to 
just what class of cells they really belong. 

These tumors are by all means most common in and about the uterus, and are 
spoken of as intramural when developing in the true uterine tissue, and submucous 
and subserous when situated closely beneath one or the other of the adjoining mem- 
branes. They differ greatly in their rate of growth, are, as a rule, quite firm in 
composition, and are moderately vascular, sometimes containing areas of softening 
and becoming even cystic. In rare instances they become enormously vascular, 
and have then been spoken of as cavernous myomata. Aside from mucoid or col- 
loid changes, such as referred to, they occasionally undergo fatty metamorphosis 
or calcareous infiltration. The latter is possible even to such an extent as to lead 
to the condition formerly spoken of as uterine calculi. 

Uterine myoma is quite liable to septic infection, which frequently follows 
exploration of the uterus o r the changes incident to pregnancy or parturition. It 
then becomes a case for immediate and most radical surgical attack. Uterine 
myomata do not occur before puberty, rarely before the age of thirty-five, and are 
most common between the thirty-fifth and forty-fifth years of life. More definite 
information concerning the enormous size which they attain or the special cha- 
racteristics which they display must be sought in the special treatises on Gyne- 
cology. They produce disaster not alone by their size, but by hemorrhage, by 
pressure on adjoining viscera (rectum, kidneys, etc.), and occasionally by torsion 
of a long pedicle. The operations, including myomectomy and hysterectomy, 
which are necessary so often for their complete removal, will be treated of at 



PLATE XV. 



■ 



\<\T.> ,' '' 



'■■■.■■ V.: 

ti <■?, - -mm. 

. . . 







7 



L 



% 




Cavernous Angeioma of Liver; a, Vascular Portion; b,e,d, 
Growing Neoplasm; c, Hepatic Tissue. (Klebs.) 



CYSTS AND TUMORS. 



333 



greater length elsewhere, while for full information the reader must necessarily be 
referred to the special treatises. 

Myomata are found in the oesophagus anywhere along its course, in the walls 
of the stomach, where they are frequently confounded with malignant tumors, and 
in the prostate and wall of the bladder. Also in connection with the skin they are 
occasionally met with. Wherever met with, so soon as they give rise to incon- 
venience or to dangerous symptoms they are to be dealt with surgically, since no 
other treatment has been proven to be of lasting benefit. 



6. TUMORS OF COMPLEX MESOBLASTIC TYPE. 

Angeioma. 

Angeiomata are tumors composed, in whole or for the most part, 
of blood-vessels, and naturally group themselves under three headings, 
in accordance with the structure of the vascular 
system : Fig. 95. 

(a) Capillary angeioma or nsevus, the most com- 
mon form of all, and frequently seen in the skin and 
subcutaneous tissue. When the condition is spread 
over a relatively large area it gives rise to a discol- 
oration known to the laity as port-wine mark. This 
is spoken of by pathologists as a telangiectasis, 
referring to vessels which are present in abnormal 
number and of abnormal size. The condition is 
often congenital or begins soon after birth. Accord- 
ing to the color of the affected area it may be deter- 
mined quickly whether the vessels belong mainly to 
the venous or to the arterial system. These tumors 
may be found in all parts of the body, upon the sur- 
face, and less often are seen upon the submucous sur- 
faces of the tongue, the inside of the mouth, the con- 
junctiva, and the vulva. The tendency is toward 
gradual increase in size ; rarely spontaneous contrac- 
tion and obliteration occur. 

(6) Cavernous Tumors — These are similar in 
structure to the corpus cavernosum, and are often 
spoken of as erectile tumors. They are most com- 
mon in connection with the skin, and are simply 
exaggerated forms of the variety first described, the 
vessels becoming not merely dilated, but cavernous 
in arrangement. They occur occasionally in the 
tongue, in the voluntary muscles, and in the liver, 
and are noted very rarely in the mammae, in the 
larynx, and subperitoneally. (Vide Plate XV.) 

A similar condition, but much more exaggerated, is met 
with in the so-called cavernous tumors which involve various 
organs, especially the thyroid and the liver. In these instances Angeioma; medullary 
a part or the whole of the organ may be involved, and pre- tu mor in shaft of hu- 
■enta .great increase in size and evidences of excessive vas- ESSSii taSg£ "111 
culanty, which one cannot fail to distinguish sometimes ceraux). 
even at a distance. In cavernous growths of the thyroid, 

tor instance, one may meet with vessels, veins especially, the size of his thumb, 
while with the ear not touching the body of the patient a distinct venous mur- 
mur may be appreciated. 



334 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

(c) Arterial or plexiform angeiomata, which when of any particu- 
lar size are ordinarily spoken of as cirsoid aneurism or aneurism by 
anastomosis. This form consists of arteries abnormal both in number, 
length, and diameter, tortuous in arrangement, occurring perhaps most 
often in the scalp, rarely in the perineum or genitalia, and exceedingly 
rarely in other parts of the body. They will be spoken of at greater 
length under the heading Aneurism in Chapter XXXI. These tumors 
are exceedingly liable to rupture from external injury, and call usually 
for ligation of the main arterial trunks, with perhaps extirpation of the 
tumor-mass. 

Recognition of angeiomata is never difficult unless they are deeply concealed. 
The effect of intermitting pressure, the emptying and refilling, and the distinction 
between arterial and venous growths by the result of alternating pressure and 
relaxation, either above or below the growth, coupled with the discoloration of the 
skin, and, in the larger growths, the very audible murmur, — all these signs should 
leave one ordinarily in little or no doubt as to the character of the growth in hand. 

When such growths are small they may be dealt with by electrolysis, 
the needles from both poles being introduced, or only from the negative, 
the positive being applied upon some neighboring portion of the body — 
perhaps with the understanding that the treatment may have to be 
repeated once or oftener in order to bring about final obliteration of the 
tumor. The effect of the electric current is to determine the coagula- 
tion of the blood in the tissues acted upon, and this, in turn, is followed 
by organization of thrombus, conversion of vascular into cicatricial 
tissue, shrinkage, and possible eventual disappearance of the mass. It 
is good treatment with many forms of these growths to make a radical 
excision under an anaesthetic, dissecting out the mass as one would any 
other tumor, securing bleeding vessels, and reuniting the parts by 
sutures, with the expectation of securing primary union. This is the 
quickest and in many cases the least disfiguring method. Old methods 
of ligation or surrounding vessels or the subcutaneous ligature are now 
practically discarded. Still worse, and to be most severely condemned, 
are the injection methods as formerly practised, especially the use of 
iron salts in solution. Death has promptly followed resort to this 
expedient, and it is now never justifiable. With the two expedients of 
electrolysis and excision the surgeon has at hand nearly all the measures 
which he will ever need to practise for the medical treatment of angei- 
omata. In exceptional cases other methods may be resorted to which it 
is not necessary to discuss here. 

Lymphangbioma. 

Lymphangeiomata are tumors composed of lymph-vessels and 
bearing an exact resemblance to the tumors just above considered. 
They may likewise be divided into three varieties : 

(a) The lymphatic nsevus, composed for the most part or entirely 
of lymphatics nearly normal in size, but abnormal in number, occasion- 
ally colored red by the presence of blood-vessels. When pricked, pure 
lymph or blood-stained lymph will flow. They are for the most part 
quite small, and are noticed during the earlier years of childhood. They 
may occur anywhere upon the surface of the body or in the mouth, most 
frequently in connection with the tongue, where they appear most often 



CYSTS AND TUMORS. 



335 



Fig. 96. 




Lymphangeioma of lip ; macrocheilia 

(Neisser). 



as large papillae involving a portion 
or all of the dorsum. When all the 
lymphatic structures of the tongue 
are thus abnormally enlarged and 
involved, the condition is known as 
maeroglossia, and consists of more or 
less enlargement of the organ, some- 
times to a degree not permitting its 
retention in the mouth, but leading 
to its constant protrusion. 

(6) Cavernous lymphangeioma 
corresponds to cavernous angeioma, 
and is a condition in which the lymph- 
vessels become positively cavernous 
and sacculated. 

(e) Lymph-cysts are the still 
more aggravated form which lym- 
phatic dilatation may attain, and are 
usually encapsulated, complicated 
with more or less tense tissue, and 
produce a condition of the parts, espe- 



Fig. 97. 



Fig. 98. 




Congenital lymphangeioma (original). Lymphangeioma of lower extremity (original). 



336 AFFECTIONS OF THE TISSUES AND TISSUE-SYSTEMS. 

daily about the scrotum and labia, to which the term elephantiasis is often 
applied. 

The old question of congenital occlusion or dilatation of lymph-channels is one which 
has been made the subject of large separate monographs (especially by Busey), 
and, while deserving of the greatest consideration, cannot be more than touched 
upon in this place. Suffice it to say that numerous tumors, essentially of lymph- 
vascular origin, are found upon the lips, in the neck, and elsewhere, which grow 
slowly, are more or less elastic and spongy upon pressure, are frequently covered 
by skin from which hair grows most luxuriantly, and in which pigment or papil- 
lomatous structures are dispersed, and by which diagnosis may be aided. These 
tumors are often spoken of as cavernous tumors, are of slow growth, and occasionally 
undergo spontaneous involution, but usually eventually call for surgical relief. 
They are often confused with branqhiogenic and other congenital cysts of the 
neck. 

The treatment for the smaller lymphatic tumors is simple, but 
here electricity is less to be relied upon and excision is more urgently 
called for. Electrolysis will cause coagulation of blood, but not of 
lymph — at least not to nearly the same extent ; consequently its useful- 
ness is restricted to blood-vascular tumors. Excision, then, is almost 
the sole, at least the best, remedy. When this is impracticable much 
can be done by galvano- or ignipuncture, the cicatricial contraction 
following multiple punctures leading often to reduction in size of the 
affected part. The enlargement of the tongue spoken of above as 
macroglossia may be treated by ignipuncture or by electrolysis, if neces- 
sary under an anaesthetic, the effect of the electric current here being 
not to produce coagulation, but apparently absorption of fibrous tissue 
and changes which come slowly rather than by obliterative processes. 

7. TUMORS OF EPITHELIAL TYPE OR OP EPIBLASTIC 

ORIGIN. 

In this general group of tumors epithelium or epiblastic tissue is the 
essential and distinctive feature. According to differences in shape and 
disposition of epithelial cells, or according to the embryological origin 
of certain complex tissues (nerve), these tumors may be arranged as 
follows : 

1. Neuroma. 

2. Papilloma. 

3. Epithelioma. 

4. Adenoma. 

5. Carcinoma. 

But of these the first, though often considered by itself, essentially 
belongs here, while the fourth and fifth may be advantageously considered 
by themselves as Tumors of Glandular-tissue Type. 

Neuroma. 

The entire nervous system is produced by infolding of the epithelial 
or epiblastic layer of the embryo. Hence the consideration of neur- 
omata in this place. 

True neuromata spring from the structures of nerve-trunks, which 
trunks may also be the site of other tumors, mainly fibromata and sar- 
comata, with which neuromata may easily be confounded. The most 
common nerve-tumor is the neuro-fibroma, which grows from the struc- 



CYSTS AND TUMORS. 337 

ture of a nerve-sheath, its long axis usually coinciding with that of the 
nerve-trunk. Tumors of this class vary greatly in size, are often mul- 
tiple, and in other instances affect nearly all the nerves in the body. 
They are extremely liable to my.coiutitous degeneration, which will account 
for many of the instances reported as myxo-neuroma, etc. They attack 
cranial and spinal nerves alike, and no nerve or nerve-root in the body 
is necessarily exempt. The sensory nerves appear more liable to attack 
than the purely motor. The nerve least often attacked is the optic. 
They are not rare upon the roots of the spinal nerves, in which location 
one may attain to such size as to press upon the cord and induce 
paraplegia. Multiple neuromata are often associated with molluscum 
fibrosum (g. v.). There is one instance on record in which one thousand 
six hundred of these tumors were found after careful dissection of the 
neuro-skeleton, and another in which at least two thousand were found, 
sixty of them involving the pneumogastric trunks and their branches. 

Plexiform neuroma is relatively rare. This means a type of nerve- 
tumor in which all the branches, for example, of a given nerve which 
are distributed to a particular area become enlarged and elongated, the 
overlying skin being stretched and thin. Such a tumor seems like a 
loose bag containing a number of vermiform bodies, resembling the 
sensation given when palpating a varicocele. On section each of the 
affected nerves reveals a quantity of myxomatous tissue replacing the 
nerve-sheath. They are in large measure congenital. 

Malignant neuroma (so called) will usually be found to be a true sar- 
coma of nerve-structures, usually of the spindle-celled variety. Trau- 
matic neuroma is most often seen in amputation-stumps, where the ter- 
minations of the divided nerves become bulbous, attaining the size of 
cherry-stones, the tumors being composed of a mixture of connective 
tissues and nerve-fibre, from which in time the true nerve-structure 
usually recedes or vanishes. They seem to form more often when sup- 
puration has been profuse or healing long delayed, and most often when 
sufficient care has not been exercised to prevent entangling of the nerve- 
ends in the scar of the wound. They give rise to a great deal of pain, 
and often necessitate re-amputation. The bulbous enlargement seems 
always the result of prolonged irritation in a nerve, and has been noted 
around various foreign bodies. 

True neuroma is innocent in tendency, though often extremely pain- 
ful. It is the sarcoma of nerve-tissue which produces signs of malig- 
nancy. A true neuroma which causes unendurable pain should be 
removed when accessible. It is sometimes possible to separate the 
tumor-mass from the balance of the nerve-trunk, and thus to remove it 
without excision of the nerve. At other times it is impossible to avoid 
division and ensuing paralysis. Whenever possible divided nerve-ends 
should be brought together by catgut suture, by which means it may be 
possible to avoid permanent loss of function. Nerve-grafting is also 
resorted to for filling such defects. Removal of painful neuromata due 
to injuries to the head has more than once been the means of curing 
traumatic epilepsy. 

Papilloma. 
The type of papilloma is the common wart, consisting of a central 
stem of fibrous tissue and blood-vessels covered by epithelial projections 
22 



338 



AFFECTIONS OF THE TISSUES AND 1 ISSUE-SYSTEMS. 



and proliferations. Papillomata are mainly sessile and villous, as well 
as occasionally met with in other forms.